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What is the most appropriate recommendation for eliminating the 2-year-old's tantrums?
- A. Give the child candy before entering the store.
- B. Ask the child to stop kicking and screaming.
- C. Explain to the child that this behavior is childish.
- D. Remind the child of how a big person acts.
Correct Answer: B
Rationale: Calmly addressing the behavior sets boundaries without reinforcing it.
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Which nursing action best conveys an interest in this client and her situation?
- A. Making frequent eye contact with her
- B. Reviewing birth control clinic literature
- C. Writing down information the client provides
- D. Avoiding long pauses between questions
Correct Answer: C
Rationale: Writing down information shows attentiveness and validates the client's concerns.
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 would lead the nurse to suspect physical abuse?
- A. The child protests when approached by the nurse.
- B. The child has patchy loss of hair.
- C. The child has a fresh bruise on the forehead.
- D. The child has an abrasion on the right knee.
Correct Answer: C
Rationale: A fresh bruise in an unusual location raises suspicion of abuse.
Which information is most appropriate for the nurse to collect at this time?
- A. The infant's weight and length
- B. The infant's breath and heart sounds
- C. The infant's head and chest circumference
- D. The infant's sucking and grasp reflexes
Correct Answer: A
Rationale: Weight and length assess growth and potential failure to thrive, relevant to the mother's concern.
If the mother asks the nurse how to appropriately discipline a child of this age, which response by the nurse is most appropriate?
- A. By identifying the consequences of unacceptable behavior to the nurse.
- B. By showing disapproval immediately after an unacceptable act
- C. By administering some form of moderate physical punishment
- D. By explaining to the toddler why certain behavior is undesirable
Correct Answer: B
Rationale: Immediate disapproval helps toddlers associate behavior with consequences.