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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The nurse correctly explains that this client's behavior is an example of which psychological defense mechanism?
- A. Displacement
- B. Regression
- C. Denial
- D. Compensation
Correct Answer: C
Rationale: Seeking contraception while suspecting pregnancy reflects denial of the reality.
On the basis of the nurse's knowledge of autistic behavior, which nursing diagnosis is most likely to be a priority in the team conference?
- A. Ineffective health maintenance
- B. Chronic low self-esteem
- C. Risk for activity intolerance
- D. Risk for self-directed violence
Correct Answer: D
Rationale: Self-directed violence is a priority due to potential self-injurious behaviors.
Which nursing action is most appropriate at this time?
- A. Postpone weighing the client until later.
- B. Confront the client about the water intake.
- C. Say nothing and weigh the client as usual.
- D. Subtract 2 lb (0.9 kg) from the client's weight.
Correct Answer: A
Rationale: Postponing weighing ensures accuracy and addresses manipulative behavior.
After conferring with the nurse, which response by the receptionist to the mother is most appropriate at this time?
- A. The clinic cannot release that information.
- B. Your daughter will return the phone call shortly.
- C. You may talk to your daughter after her examination.
- D. Your daughter came to the clinic for birth control.
Correct Answer: A
Rationale: Confidentiality protects the teen's privacy, especially for reproductive health.
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.