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 information given to the teenage mother is most appropriate?
- A. Holding will not result in spoiling the baby.
- B. Grandparents usually spoil babies.
- C. Babies need to be spoiled.
- D. Toddlers are more likely to be spoiled.
Correct Answer: A
Rationale: Reassuring the mother that holding is beneficial promotes bonding and reduces unnecessary worry.
When crisis intervention is provided, which nursing action takes priority?
- A. Explaining the benefits of professional counseling
- B. Encouraging the survivors to talk about the event
- C. Reassuring the survivors that they will adapt
- D. Advising consulting a physician for drug therapy
Correct Answer: B
Rationale: Talking about the event helps process trauma and is a priority in crisis intervention.
If the 3-year-old child is typical of other autistic children, how would the nurse expect that child to respond to its parents?
- A. Indifference
- B. Playfulness
- C. Impatience
- D. None of the above
Correct Answer: A
Rationale: Autistic children often show indifference to social interactions.
If the mother asks the nurse how to appropriately discipline a child of this age, which response by the nurse is most appropriate?
- A. By identifying the consequences of unacceptable behavior to the nurse.
- B. By showing disapproval immediately after an unacceptable act
- C. By administering some form of moderate physical punishment
- D. By explaining to the toddler why certain behavior is undesirable
Correct Answer: B
Rationale: Immediate disapproval helps toddlers associate behavior with consequences.
Of the following community resources, which referral is the nurse most likely to suggest for this client?
- A. Alcoholics Anonymous
- B. Al-Anon
- C. Alateen
- D. The Substance Abuse Council
Correct Answer: C
Rationale: Alateen supports teens affected by a family member's alcoholism.