Nokea
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.
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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.
When describing the characteristic developmental stage of school-age children, which statement by the nurse is most accurate?
- A. School-age children begin developing long-lasting friendships.
- B. School-age children are learning to work beside and with others.
- C. School-age children are preoccupied with finding a purpose in life.
- D. School-age children are striving for independence from others.
Correct Answer: B
Rationale: School-age children focus on industry, working collaboratively, per Erikson's stages.
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 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.
Which statement is the best explanation for the adolescent's behavior?
- A. Aggression is a common behavior manifested by cognitively disabled people.
- B. Aggression is a response that occurs when a person feels frustrated or frightened.
- C. Aggression is an indication that the client has a poor opinion of the care provided.
- D. Aggression is a common way for adolescents to communicate they are experiencing pain.
Correct Answer: B
Rationale: Frustration or fear often triggers aggression in cognitively disabled individuals.