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The nurse notes that a toddler has numerous bruises, a possible fractured left humerus, and several lacerations. Which action will the nurse take first?
- A. Report findings to Child Protective Services.
- B. Ask the parents what caused the injuries.
- C. Review the client's previous medical record.
- D. Observe the interaction between the parents and client.
Correct Answer: A
Rationale: Suspected child abuse, indicated by multiple bruises, a possible fracture, and lacerations, requires immediate reporting to Child Protective Services as mandated by law to ensure the child's safety. This takes precedence over other actions to initiate protective measures promptly.
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When assessing the mental status of a young school-aged child, which action would be important for the nurse to take?
- A. Listen to the parents' description of the child's behavior.
- B. Compare the child's function from one occasion to another.
- C. Engage the parents in a discussion about the child's feelings.
- D. Determine the child's mental status through direct questioning.
Correct Answer: B
Rationale: To accurately assess the mental status of a young school-aged child, it is crucial for the nurse to compare the child's function over time. This approach allows for a more objective evaluation of the child's mental status. While listening to the parents' description of the child's behavior can provide valuable insights, it may be biased and subjective. Engaging parents in discussions about the child's feelings is important for overall understanding but may not directly assess the child's mental status. Directly questioning the child about their mental status can be threatening and may lead to anxiety, making it a less optimal approach compared to observing and comparing the child's function over time.
When assessing an older adult, which vital sign changes would the nurse recognize as occurring with aging?
- A. Increase in pulse rate
- B. Widened pulse pressure
- C. Increase in body temperature
- D. Decrease in diastolic blood pressure
Correct Answer: B
Rationale: When assessing an older adult, the nurse should be aware that with aging, systolic blood pressure tends to increase, resulting in widened pulse pressure. While in many older individuals both systolic and diastolic pressures increase, the pulse rate and body temperature typically do not increase with aging. Therefore, the correct answer is widened pulse pressure. Choices A, C, and D are incorrect because pulse rate does not necessarily increase with age, body temperature generally remains stable, and diastolic blood pressure may increase instead of decreasing in many older adults.
Which therapeutic technique can the nurse use when an anxious client exhibits pressured and rambling speech?
- A. Touch
- B. Silence
- C. Focusing
- D. Summarizing
Correct Answer: C
Rationale: Focusing is the appropriate therapeutic technique to use when an anxious client exhibits pressured and rambling speech. By focusing on one specific aspect, the intended meaning is easier to understand and helps the client stay on track. Touch is not recommended in this scenario as it can invade the client's personal space and potentially increase anxiety. Silence may allow the client to continue rambling without addressing the underlying concerns. Summarizing requires the identification and exploration of the client's concerns, which may be challenging when the speech is pressured and disorganized.
A client who has undergone a mastectomy because of breast cancer is now undergoing chemotherapy, which has caused hair loss. The client states, 'I feel like I've lost my sense of power.' Which response would the nurse give?
- A. Hair does not empower a person.'
- B. Losing power seems important to you.'
- C. Knowledge is power; I'll give you some pamphlets to read.'
- D. Hair loss is common; it will grow back, so you should not worry.'
Correct Answer: B
Rationale: The correct response is, 'Losing power seems important to you.' This response acknowledges the client's feelings and provides an opportunity for further discussion. Choice A is confrontational and dismissive, potentially shutting down communication. Choice C offers pamphlets, which may be seen as dismissing the client's concerns and avoiding engaging in a conversation. Choice D minimizes the client's feelings and may discourage further expression of emotions. By choosing option B, the nurse shows empathy and encourages the client to explore their emotions in a supportive environment.
The nurse in the psychiatric day program provides care for a client diagnosed with recurrent depression. In doing the initial assessment based on the therapist's recommendation for a cognitive approach to therapy, which aspect is important for the nurse to evaluate?
- A. The client's use of language.
- B. The client's insight into the depression.
- C. The client's socialization history and skills.
- D. The client's attitude toward medications.
Correct Answer: B
Rationale: Cognitive therapy focuses on thought patterns and self-awareness. Evaluating the client's insight into their depression is critical to assess their understanding of their condition and tailor therapy effectively. Other aspects are less directly tied to cognitive approaches.