Nokea
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.
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What is the best guidance the nurse can give the mental health technician caring for the anorectic client?
- A. Blend the food and administer it by tube feeding.
- B. Remind the client that the intake is being recorded.
- C. Review the treatment goals with the client again.
- D. Remove the food without making any comments.
Correct Answer: D
Rationale: Removing food without comment avoids power struggles and maintains neutrality.
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.
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 nursing instruction is most appropriate when teaching a client who self-administers haloperidol (Haldol)?
- A. Take the pills on an empty stomach.
- B. Do not skip meals while taking the drug.
- C. Stop taking the drug if sedation occurs.
- D. Rise slowly from a sitting position.
Correct Answer: D
Rationale: Rising slowly prevents orthostatic hypotension, a common side effect.
If the teenage mother expresses feeling inexperienced and inadequate in caring for the baby, which referral is best?
- A. Project Head Start
- B. Planned Parenthood
- C. Parent-Teacher Association
- D. Parenting classes
Correct Answer: D
Rationale: Parenting classes provide education and support to build confidence and skills.