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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.
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.
What is the best suggestion the nurse can give the nursing assistant caring for the 2-year-old child at this time?
- A. Let the child choose from two acceptable alternatives.
- B. Withhold something the child desires until the child complies.
- C. Identify what is expected of the child, rather than ask.
- D. Inform the mother if the child continues to be uncooperative.
Correct Answer: A
Rationale: Offering choices fosters autonomy while maintaining boundaries.
If this child is typical of others the same age with a serious illness, which concept is the most commonly held belief about being ill?
- A. Illness is not life-threatening; recovery is assured.
- B. Significant others can prevent serious consequences.
- C. Illness is a punishment for some wrong-doing.
- D. Failure to comply with treatment results in parental rejection.
Correct Answer: C
Rationale: School-age children often view illness as punishment due to magical thinking.
When discussing the home environment with the parents, the nurse should explain that which one of the following is the most appropriate environment for an autistic child?
- A. Stimulating, with a variety of sensory experiences
- B. Consistent, with a minimum of physical change
- C. Flexible, with the freedom to initiate activity
- D. Strict, with narrow limits for acceptable behavior
Correct Answer: B
Rationale: Consistency minimizes anxiety and supports routine.