Nokea
On the basis of the principles of crisis intervention, when is the best time for the nurse to offer assistance to those most affected by this incident?
- A. After the funeral
- B. Within 6 months
- C. Immediately
- D. Six weeks later
Correct Answer: C
Rationale: Immediate intervention addresses acute distress and prevents long-term issues.
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Which information is most appropriate for the nurse to collect at this time?
- A. The infant's weight and length
- B. The infant's breath and heart sounds
- C. The infant's head and chest circumference
- D. The infant's sucking and grasp reflexes
Correct Answer: A
Rationale: Weight and length assess growth and potential failure to thrive, relevant to the mother's concern.
When the teenager makes an appointment at a birth control clinic, which nursing attribute is most important to communicate during the initial meeting?
- A. Efficiency
- B. Intelligence
- C. Nonjudgmental attitude
- D. Acceptance
Correct Answer: D
Rationale: Acceptance creates a safe space for the teen to discuss sensitive issues.
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.
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.
To ensure optimum mental health of an infant born with a congenital defect such as myelomeningocele, the nurse explains that it is essential for the parents to meet which of the following needs?
- A. Autonomy
- B. Love
- C. Respect
- D. Identity
Correct Answer: B
Rationale: Love and attachment are critical for the infant's emotional and mental health development.