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Which nursing goal is the highest priority at this time?
- A. To improve the client's distorted body image
- B. To help the client use healthier coping techniques
- C. To restore normal nutrition and health
- D. To help the client develop assertiveness
Correct Answer: C
Rationale: Restoring nutrition is critical to address life-threatening malnutrition.
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If the adolescent who is involved in gang activities demonstrates the following behaviors during group meetings, which is most indicative of resistance to therapy?
- A. The adolescent borrows cigarettes from others.
- B. The adolescent laughs inappropriately.
- C. The adolescent keeps checking the clock.
- D. The adolescent fidgets in the chair.
Correct Answer: B
Rationale: Inappropriate laughter suggests discomfort or dismissal of the therapeutic process.
Which test should the nurse use to more objectively assess the toddler's overall development?
- A. Denver II Developmental Screening Test
- B. Scholastic Aptitude Test (SAT)
- C. Stanford-Binet test
- D. Weber's test
Correct Answer: A
Rationale: The Denver II is designed to screen developmental milestones in young children.
During the nursing assessment, which of the following suggests that the mother may be continuing to abuse heroin?
- A. The mother states, 'I am tired all the time and find myself needing to sleep when the baby sleeps.'
- B. The nurse notes a variety of small ecchymotic areas on the arms and legs of the mother.
- C. The mother appears indifferent to the crying of the newborn.
- D. The mother has a body odor and the newborn appears unkempt.
- E. The mother expresses an inability to afford public transportation to the clinic.
- F. The mother states that the father of the child is no longer associated with the family.
Correct Answer: B,C,D
Rationale: Ecchymotic areas suggest injection sites, indifference may indicate substance use, and poor hygiene is a common sign of ongoing abuse.
If the adolescent is typical of others who have grown up in an alcoholic family, the nurse would expect to assess for problems in which area?
- A. Low self-esteem
- B. Managing stress
- C. Long-term learning
- D. Fear of authority
Correct Answer: A
Rationale: Low self-esteem is common in children of alcoholics due to unpredictable environments.
After receiving the news about her pregnancy, which of the following occurrences is most beneficial to the pregnant adolescent at this time?
- A. A positive mothering instinct
- B. Making plans for marriage
- C. Financial support from her boyfriend
- D. Emotional support from her family
Correct Answer: D
Rationale: Family emotional support is critical for the teen's well-being during pregnancy.