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When the nurse documents this incident, which wording is most appropriate?
- A. Became angry for no reason and an assault occurred.
- B. Hit caregiver unexpectedly even though not provoked.
- C. Struck nursing assistant when being helped from bed.
- D. Attacked nursing assistant without prior warning.
Correct Answer: C
Rationale: Objective language like 'struck' accurately describes the incident without bias.
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Which statement regarding hospital admittance is most accurate?
- A. The client cannot be committed involuntarily unless the client is uncooperative at this time.
- B. The client cannot be committed involuntarily unless the client poses harm to self or others.
- C. The client cannot be committed involuntarily unless the client cancels office appointments.
- D. The client cannot be committed involuntarily unless the client refuses to take medications.
Correct Answer: B
Rationale: Involuntary commitment requires evidence of harm to self or others.
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 adolescent is typical of others who have grown up in an alcoholic family, the nurse would expect to assess for problems in which area?
- A. Low self-esteem
- B. Managing stress
- C. Long-term learning
- D. Fear of authority
Correct Answer: A
Rationale: Low self-esteem is common in children of alcoholics due to unpredictable environments.
Which is most therapeutic for the nurse to say privately to the parent in this situation?
- A. All children know how to frustrate parents.
- B. You need to stop pleading with your child to eat.
- C. You're concerned that your child is starving.
- D. I know how you're feeling; I'm a parent, too.
Correct Answer: C
Rationale: Acknowledging concern validates the parent's emotions and opens dialogue.
Which assessment findings are most characteristic of a 10-month-old infant with the diagnosis of failure to thrive?
- A. The infant cries vigorously when handled.
- B. The infant has a delay in developmental milestones.
- C. The infant appears pale and lethargic.
- D. The infant's sucking and grasp reflexes
- E. The infant has delayed understanding of speech.
Correct Answer: B,C,E
Rationale: Delayed milestones, pallor, lethargy, and speech delays are hallmark signs of failure to thrive.