Nokea
Which nursing approach is most appropriate to encourage the maximum level of independence possible?
- A. Allowing the teen to select the foods for his or her diet
- B. Answering all the teen's medical questions
- C. Exaggerating the teen's accomplishments
- D. Assuming blame for the teen's condition
Correct Answer: A
Rationale: Allowing food choices promotes autonomy within safe boundaries.
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Which of the following behaviors exhibited by the child demonstrates the most severe reaction to prolonged hospitalization?
- A. Clinging to the parents
- B. Shaking the crib frantically
- C. Thrashing about
- D. Ignoring the parents
Correct Answer: D
Rationale: Ignoring parents indicates severe emotional withdrawal, a significant concern.
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.
The nurse correctly explains that this is normal behavior for toddlers who are developing which psychosocial characteristic?
- A. Integrity
- B. Identity
- C. Autonomy
- D. Generativity
Correct Answer: C
Rationale: The 'no' phase reflects toddlers asserting autonomy, per Erikson's stages.
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.
Which additional nursing action is most beneficial for reducing the child's anxiety?
- A. Offer the child a reward for good behavior.
- B. Let the child handle some of the equipment.
- C. Show the child others who have infusing fluids.
- D. None of the above
Correct Answer: B
Rationale: Handling equipment familiarizes the child with the procedure, reducing fear.