Nokea
What information strongly suggests that the child's fractured femur is the result of physical abuse?
- A. The nurse notes evidence of other healed fractures.
- B. Only the mother witnessed the injury.
- C. The child is not fully immunized yet.
- D. The child is underweight for height.
Correct Answer: A
Rationale: Multiple healed fractures suggest a pattern of abuse.
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When reviewing the assessment data, the nurse would expect to note which characteristic physical finding?
- A. Extremely low body weight
- B. Erosion of dental enamel
- C. Cessation of menstruation
- D. Patchy loss of hair
Correct Answer: B
Rationale: Erosion of dental enamel is caused by frequent vomiting in bulimia.
Which strategy is most appropriate for developing a positive, therapeutic relationship with the injured child at the time of assessment?
- A. The nurse should make an effort to have prolonged eye contact with the child.
- B. The nurse should maintain a body position at the same level as the child.
- C. The nurse should separate the child from the parent during the interview.
- D. The nurse should ask the child direct questions about the parent.
Correct Answer: B
Rationale: A non-threatening posture at the child's level builds trust.
Which assessment finding best indicates that a child taking methylphenidate hydrochloride (Ritalin) is experiencing undesirable side effects?
- A. The child has altered elimination patterns.
- B. The child develops intolerance to certain foods.
- C. The child has an elevated blood pressure.
- D. The child has evidence of skin breakdown.
Correct Answer: C
Rationale: Elevated blood pressure is a concerning side effect of Ritalin.
Which warning signs of suicide should the nurse include?
- A. Withdrawal
- B. Apathy
- C. Angry outbursts
- D. Lower standardized test scores in reading and math
- E. Delusions
- F. Incoherent speech
Correct Answer: A,B,C
Rationale: Withdrawal, apathy, and angry outbursts are common suicide warning signs.
Which nursing instruction is most appropriate when teaching a client who self-administers haloperidol (Haldol)?
- A. Take the pills on an empty stomach.
- B. Do not skip meals while taking the drug.
- C. Stop taking the drug if sedation occurs.
- D. Rise slowly from a sitting position.
Correct Answer: D
Rationale: Rising slowly prevents orthostatic hypotension, a common side effect.