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If this diagnosis is accurate, it is most important for the nurse to assess for which characteristic finding?
- A. The mother is obsessed with the fear that her child will die.
- B. The mother is well versed in normal health patterns among children.
- C. The mother is responsible for creating the child's symptoms.
- D. The mother is overreacting to minor variations in her child's health.
Correct Answer: C
Rationale: Munchausen syndrome by proxy involves a caregiver causing or fabricating symptoms.
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When reviewing the assessment data, the nurse would expect to note which characteristic physical finding?
- A. Extremely low body weight
- B. Erosion of dental enamel
- C. Cessation of menstruation
- D. Patchy loss of hair
Correct Answer: B
Rationale: Erosion of dental enamel is caused by frequent vomiting in bulimia.
When the nurse documents this incident, which wording is most appropriate?
- A. Became angry for no reason and an assault occurred.
- B. Hit caregiver unexpectedly even though not provoked.
- C. Struck nursing assistant when being helped from bed.
- D. Attacked nursing assistant without prior warning.
Correct Answer: C
Rationale: Objective language like 'struck' accurately describes the incident without bias.
During the nursing assessment, which of the following suggests that the mother may be continuing to abuse heroin?
- A. The mother states, 'I am tired all the time and find myself needing to sleep when the baby sleeps.'
- B. The nurse notes a variety of small ecchymotic areas on the arms and legs of the mother.
- C. The mother appears indifferent to the crying of the newborn.
- D. The mother has a body odor and the newborn appears unkempt.
- E. The mother expresses an inability to afford public transportation to the clinic.
- F. The mother states that the father of the child is no longer associated with the family.
Correct Answer: B,C,D
Rationale: Ecchymotic areas suggest injection sites, indifference may indicate substance use, and poor hygiene is a common sign of ongoing abuse.
Besides involuntary tremors, which other side effect should the nurse advise the family to anticipate?
- A. Muscle weakness
- B. Muscle atrophy
- C. Muscle contractures
- D. None of the above
Correct Answer: A
Rationale: Haloperidol can cause extrapyramidal symptoms, including muscle weakness.
If the adolescent is typical of others who have grown up in an alcoholic family, the nurse would expect to assess for problems in which area?
- A. Low self-esteem
- B. Managing stress
- C. Long-term learning
- D. Fear of authority
Correct Answer: A
Rationale: Low self-esteem is common in children of alcoholics due to unpredictable environments.