Which of the following risk factors would the nurse expect to note when assessing the mother?
- A. The pregnancy was unplanned and unwanted.
- B. The baby's father abandoned the mother.
- C. The mother is an adolescent.
- D. The mother's socioeconomic status is low.
- E. The mother has a history of alcohol and drug abuse.
- F. The mother has dropped out of high school.
Correct Answer: A,C,D,E
Rationale: Unplanned pregnancy, adolescent motherhood, low socioeconomic status, and substance abuse are risk factors for failure to thrive.
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Which strategy is most appropriate for developing a positive, therapeutic relationship with the injured child at the time of assessment?
- A. The nurse should make an effort to have prolonged eye contact with the child.
- B. The nurse should maintain a body position at the same level as the child.
- C. The nurse should separate the child from the parent during the interview.
- D. The nurse should ask the child direct questions about the parent.
Correct Answer: B
Rationale: A non-threatening posture at the child's level builds trust.
Which response by the nurse to the parents is most appropriate at this time?
- A. The physicians here are very well qualified.
- B. This diagnosis is difficult for you to accept.
- C. Why do you feel you need a second opinion?
- D. It's not as bad as it may seem right now.
Correct Answer: B
Rationale: Acknowledging the difficulty of accepting the diagnosis validates the parents' emotions and opens communication without being confrontational.
When reviewing the assessment data, the nurse would expect to note which characteristic physical finding?
- A. Extremely low body weight
- B. Erosion of dental enamel
- C. Cessation of menstruation
- D. Patchy loss of hair
Correct Answer: B
Rationale: Erosion of dental enamel is caused by frequent vomiting in bulimia.
What is the most appropriate recommendation for eliminating the 2-year-old's tantrums?
- A. Give the child candy before entering the store.
- B. Ask the child to stop kicking and screaming.
- C. Explain to the child that this behavior is childish.
- D. Remind the child of how a big person acts.
Correct Answer: B
Rationale: Calmly addressing the behavior sets boundaries without reinforcing it.
If the nurse's suspicions are true, which assessment findings require further investigation?
- A. The child demonstrates sexual activity with a doll.
- B. The child has a gonorrheal infection.
- C. The child is underweight for the corresponding height.
- D. The child complains of burning during urination.
- E. The child is afraid to be left alone with the suspected nurse.
- F. The child has trouble sleeping through the night.
Correct Answer: A,B,D
Rationale: Sexual behavior, gonorrhea, and urinary symptoms are strong indicators of sexual abuse.