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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.
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Which response by the nurse to the parents is most appropriate at this time?
- A. The physicians here are very well qualified.
- B. This diagnosis is difficult for you to accept.
- C. Why do you feel you need a second opinion?
- D. It's not as bad as it may seem right now.
Correct Answer: B
Rationale: Acknowledging the difficulty of accepting the diagnosis validates the parents' emotions and opens communication without being confrontational.
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.
Which of the following data best correlate with the profile of a person with anorexia nervosa?
- A. The teen is the middle child of three siblings.
- B. The teen is a high achiever in school and activities.
- C. The teen thinks that classmates are not friendly.
- D. The teen experienced many illnesses during childhood.
Correct Answer: B
Rationale: High achievement and perfectionism are common in anorexia profiles.
When the parents ask about the side effects of taking methylphenidate hydrochloride (Ritalin), the nurse correctly explains that the child may have which common cluster of signs and symptoms?
- A. Nausea, vomiting, and diarrhea
- B. Fatigue, drowsiness, and dry mouth
- C. Insomnia, tachycardia, and anorexia
- D. Hypotension, bradycardia, and constipation
Correct Answer: C
Rationale: Insomnia, tachycardia, and anorexia are common side effects of Ritalin.
Which nursing strategy is best to help the child overcome the fear of being in the unfamiliar hospital environment?
- A. Bringing a favorite blanket from home
- B. Providing age-specific toys such as a stuffed animal
- C. Having one or both parents nearby at all times
- D. Placing the child in a room with a same-aged child
Correct Answer: C
Rationale: Parental presence provides the most comfort and security for a young child.