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What is the best suggestion the nurse can give the nursing assistant caring for the 2-year-old child at this time?
- A. Let the child choose from two acceptable alternatives.
- B. Withhold something the child desires until the child complies.
- C. Identify what is expected of the child, rather than ask.
- D. Inform the mother if the child continues to be uncooperative.
Correct Answer: A
Rationale: Offering choices fosters autonomy while maintaining boundaries.
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Besides involuntary tremors, which other side effect should the nurse advise the family to anticipate?
- A. Muscle weakness
- B. Muscle atrophy
- C. Muscle contractures
- D. None of the above
Correct Answer: A
Rationale: Haloperidol can cause extrapyramidal symptoms, including muscle weakness.
Which of the following is the best indication that haloperidol (Haldol) is achieving a therapeutic effect?
- A. The client no longer hears voices.
- B. The client sleeps more than before.
- C. The client thinks of himself or herself as a good person.
- D. The client feels more energetic and rested.
Correct Answer: A
Rationale: Reduction in hallucinations indicates therapeutic efficacy.
If the adolescent who is involved in gang activities demonstrates the following behaviors during group meetings, which is most indicative of resistance to therapy?
- A. The adolescent borrows cigarettes from others.
- B. The adolescent laughs inappropriately.
- C. The adolescent keeps checking the clock.
- D. The adolescent fidgets in the chair.
Correct Answer: B
Rationale: Inappropriate laughter suggests discomfort or dismissal of the therapeutic process.
Which nursing goal is the highest priority at this time?
- A. To improve the client's distorted body image
- B. To help the client use healthier coping techniques
- C. To restore normal nutrition and health
- D. To help the client develop assertiveness
Correct Answer: C
Rationale: Restoring nutrition is critical to address life-threatening malnutrition.
Which of the following nursing interventions is most appropriate to include when preparing a care plan for the child in the educational setting?
- A. Work with the teacher to establish clear behavioral expectations for the classroom.
- B. Place a chair in the corner of the room as a potential consequence for poor behavior.
- C. Allow the child to move about the room as desired provided the behavior is not disruptive.
- D. Plan separate learning experiences with more creative assignments and activities.
Correct Answer: A
Rationale: Clear expectations provide structure, beneficial for ADHD management.