Nokea
On the basis of the nurse's knowledge of autistic behavior, which nursing diagnosis is most likely to be a priority in the team conference?
- A. Ineffective health maintenance
- B. Chronic low self-esteem
- C. Risk for activity intolerance
- D. Risk for self-directed violence
Correct Answer: D
Rationale: Self-directed violence is a priority due to potential self-injurious behaviors.
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If the nurse's suspicions are true, which assessment findings require further investigation?
- A. The child demonstrates sexual activity with a doll.
- B. The child has a gonorrheal infection.
- C. The child is underweight for the corresponding height.
- D. The child complains of burning during urination.
- E. The child is afraid to be left alone with the suspected nurse.
- F. The child has trouble sleeping through the night.
Correct Answer: A,B,D
Rationale: Sexual behavior, gonorrhea, and urinary symptoms are strong indicators of sexual abuse.
Which suggestion is most appropriate for the nurse to offer the parents in this situation?
- A. Avoid controlling the child.
- B. Praise accomplishments as deserved.
- C. Avoid discussing peer comments.
- D. Show disapproval of negative labels.
Correct Answer: B
Rationale: Praising accomplishments boosts self-esteem and counters ridicule.
The nurse recognizes that methylphenidate hydrochloride (Ritalin) is classified as which type of drug?
- A. Central nervous system depressant
- B. Central nervous system stimulant
- C. Antidepressant
- D. Tranquilizer
Correct Answer: B
Rationale: Methylphenidate is a CNS stimulant used for ADHD.
After receiving the news about her pregnancy, which of the following occurrences is most beneficial to the pregnant adolescent at this time?
- A. A positive mothering instinct
- B. Making plans for marriage
- C. Financial support from her boyfriend
- D. Emotional support from her family
Correct Answer: D
Rationale: Family emotional support is critical for the teen's well-being during pregnancy.
Which assessment finding would lead the nurse to suspect physical abuse?
- A. The child protests when approached by the nurse.
- B. The child has patchy loss of hair.
- C. The child has a fresh bruise on the forehead.
- D. The child has an abrasion on the right knee.
Correct Answer: C
Rationale: A fresh bruise in an unusual location raises suspicion of abuse.