Nokea
The nurse is assessing an 8-year-old child?s self-concept. Which of the following would be least appropriate for the nurse to ask?
- A. If you had three wishes, what would you wish for?
- B. What would you like to be when you grow up?
- C. What subjects do you like best in school?
- D. What did you have for breakfast this morning?
Correct Answer: D
Rationale: Asking about breakfast (D) is unrelated to self-concept, which involves self-perception and aspirations. Questions about wishes (A), future goals (B), and school preferences (C) elicit insights into the child?s self-view and identity.
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To establish rapport with a 10-year-old child who is hospitalized in a psychiatric setting, which statement by the nurse would be most appropriate?
- A. Let?s compare your situation to that of Cinderella?s in the fairy tale.
- B. I?m going to use the DECA tool to measure your self-control and initiative.
- C. Let?s have you draw a picture of yourself.
- D. Would you like to play a game of checkers with me?
Correct Answer: D
Rationale: Playing a game like checkers (D) is an engaging, non-threatening way to build rapport with a 10-year-old. Comparing to a fairy tale (A) may confuse, mentioning assessment tools (B) is too clinical, and drawing (C) may feel directive before trust is established.
A nurse is preparing to assess a 9-year-old child who has been sexually abused. Which of the following would be the priority for the nurse?
- A. Finding out when the abuse occurred
- B. Documenting the assessment for use in court
- C. Using anatomically correct dolls to elicit information
- D. Ensuring that the environment is safe and supportive
Correct Answer: D
Rationale: Ensuring a safe and supportive environment (D) is the priority to reduce trauma and build trust during assessment. Timing (A), documentation (B), and dolls (C) are secondary to creating a secure setting for the child.
A nurse is preparing to complete a mental status examination of an adolescent who is experiencing behavioral problems at school. When assessing the adolescent?s thought processes, which of the following would the nurse need to keep in mind about this age group? Select all that apply.
- A. View of things in a concrete manner
- B. Ability to look at things hypothetically
- C. Beginning ability to use logic
- D. Ability to use abstract thinking
- E. Difficulty in putting feelings into words
Correct Answer: B,C,D,E
Rationale: Adolescents develop hypothetical thinking (B), logical reasoning (C), abstract thinking (D), and often struggle to verbalize feelings (E). Concrete thinking (A) is more typical of younger children.
The nurse is beginning an assessment interview with an 8-year-old girl who has been brought in for counseling by her parents. When beginning the interview, which question would be most appropriate for the nurse to ask first?
- A. How are you feeling?
- B. How old are you?
- C. Has anyone told you about why you are here today?
- D. Why do you think I?m talking to you alone without your parents here?
Correct Answer: C
Rationale: Asking if the child knows why she is there (C) is a gentle, open-ended start that clarifies her understanding and builds rapport. Asking about feelings (A) may be too direct initially, age (B) is factual but less engaging, and questioning the absence of parents (D) may raise anxiety.
After completing the mental status assessment of a 9-year-old boy, the nurse documents the findings. Which of the following would the nurse document as reflecting the child?s motor activity? Select all that apply.
- A. Favorite story, Huckleberry Finn
- B. Short attention span
- C. Hyperalertness
- D. Went to the park last weekend
- E. Nail biting
- F. History of temper tantrums
Correct Answer: B,C,E,F
Rationale: Motor activity includes short attention span (B), hyperalertness (C), nail biting (E), and temper tantrums (F), as they reflect observable behaviors. Favorite story (A) and park visits (D) are not motor-related.