Nokea
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.
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Which behavior best indicates that an adolescent is at increased risk for suicide?
- A. Disobeying family rules
- B. Arguing with siblings
- C. Letting his grade average drop from a 92 to 88
- D. Becoming depressed over a recent breakup with a girlfriend
Correct Answer: D
Rationale: Depression following a breakup is a significant risk factor for suicide.
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 warning signs of suicide should the nurse include?
- A. Withdrawal
- B. Apathy
- C. Angry outbursts
- D. Lower standardized test scores in reading and math
- E. Delusions
- F. Incoherent speech
Correct Answer: A,B,C
Rationale: Withdrawal, apathy, and angry outbursts are common suicide warning signs.
What advice is most appropriate to give the parents at this time?
- A. Tell the parents to disregard their son's behavior; it is normal grieving.
- B. Advise the parents to tell their son to snap out of it; his life is not over.
- C. Suggest transferring their son to another school.
- D. Advise the parents to ask their son about having thoughts of suicide.
Correct Answer: D
Rationale: Directly addressing suicidal thoughts is critical for safety.
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.