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What information is most helpful for the nurse to obtain next?
- A. The mother's expectations of an infant's behavior
- B. If the mother plans to finish high school
- C. The kinds of toys the mother has for the baby
- D. None of the above
Correct Answer: A
Rationale: Understanding the mother's expectations helps identify misconceptions contributing to the concern.
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If ruminations about suicide are present, which observation by the nurse is most significant?
- A. The teen is not attending school regularly.
- B. The teen is hoarding sharp objects in the bedroom.
- C. The teen is not completing homework assignments.
- D. The teen is not participating in extracurricular activities.
Correct Answer: B
Rationale: Hoarding sharp objects indicates a high risk for self-harm.
Which assessment finding is most indicative that the child is developmentally delayed?
- A. The child is being bottle-fed.
- B. The child is not toilet-trained.
- C. The child has no language skills.
- D. The child cannot draw a picture.
Correct Answer: C
Rationale: Lack of language skills at age 2 is a significant indicator of developmental delay.
Which test should the nurse use to more objectively assess the toddler's overall development?
- A. Denver II Developmental Screening Test
- B. Scholastic Aptitude Test (SAT)
- C. Stanford-Binet test
- D. Weber's test
Correct Answer: A
Rationale: The Denver II is designed to screen developmental milestones in young children.
Which of the following risk factors would the nurse expect to note when assessing the mother?
- A. The pregnancy was unplanned and unwanted.
- B. The baby's father abandoned the mother.
- C. The mother is an adolescent.
- D. The mother's socioeconomic status is low.
- E. The mother has a history of alcohol and drug abuse.
- F. The mother has dropped out of high school.
Correct Answer: A,C,D,E
Rationale: Unplanned pregnancy, adolescent motherhood, low socioeconomic status, and substance abuse are risk factors for failure to thrive.
If the adolescents who witnessed the violence at school are typical of others who experience crises, how are they most likely feeling?
- A. Helpless
- B. Depressed
- C. Angry
- D. Fortunate
Correct Answer: A
Rationale: Helplessness is a common response to traumatic events.