Nokea
Which nursing action best conveys an interest in this client and her situation?
- A. Making frequent eye contact with her
- B. Reviewing birth control clinic literature
- C. Writing down information the client provides
- D. Avoiding long pauses between questions
Correct Answer: C
Rationale: Writing down information shows attentiveness and validates the client's concerns.
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During the initial physical examination, the nurse is most likely to detect which finding related to anorexia?
- A. Growth of fine body hair
- B. Bruises over the upper torso
- C. Hyperactive bowel sounds
- D. Club-shaped fingertips
Correct Answer: A
Rationale: Lanugo (fine body hair) develops in anorexia due to malnutrition.
Which is most therapeutic for the nurse to say privately to the parent in this situation?
- A. All children know how to frustrate parents.
- B. You need to stop pleading with your child to eat.
- C. You're concerned that your child is starving.
- D. I know how you're feeling; I'm a parent, too.
Correct Answer: C
Rationale: Acknowledging concern validates the parent's emotions and opens dialogue.
If this diagnosis is accurate, it is most important for the nurse to assess for which characteristic finding?
- A. The mother is obsessed with the fear that her child will die.
- B. The mother is well versed in normal health patterns among children.
- C. The mother is responsible for creating the child's symptoms.
- D. The mother is overreacting to minor variations in her child's health.
Correct Answer: C
Rationale: Munchausen syndrome by proxy involves a caregiver causing or fabricating symptoms.
Which response by the nurse provides the best explanation of the child's behavior?
- A. Thumb sucking is a primitive form of self-stimulation and security.
- B. Thumb sucking is a regressive behavior with a comforting effect.
- C. Thumb sucking substitutes for the missing fluids due to postoperative restriction of fluids.
- D. Thumb sucking satisfies the child's increased need for a familiar touch.
Correct Answer: B
Rationale: Thumb sucking is a regressive behavior triggered by stress, offering comfort.
If the following facts are present in the social history of a person suspected of child abuse, which one is most similar to the profile of other child abusers?
- A. The person grew up in a divorced household.
- B. The person's income is at or below poverty level.
- C. The person was the victim of child abuse.
- D. The person became a parent after age 25.
Correct Answer: C
Rationale: A history of being abused increases the risk of becoming an abuser.