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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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The nurse correctly explains that the behavior the preschooler is demonstrating is based on a need to feel what?
- A. Powerful
- B. Secure
- C. Confident
- D. Dependent
Correct Answer: B
Rationale: Preschoolers seek security in stressful situations.
Besides involuntary tremors, which other side effect should the nurse advise the family to anticipate?
- A. Muscle weakness
- B. Muscle atrophy
- C. Muscle contractures
- D. None of the above
Correct Answer: A
Rationale: Haloperidol can cause extrapyramidal symptoms, including muscle weakness.
Which warning signs of suicide should the nurse include?
- A. Withdrawal
- B. Apathy
- C. Angry outbursts
- D. Lower standardized test scores in reading and math
- E. Delusions
- F. Incoherent speech
Correct Answer: A,B,C
Rationale: Withdrawal, apathy, and angry outbursts are common suicide warning signs.
Which instruction is most important for the nurse to recommend to the teenage mother regarding parenting the infant?
- A. Give the baby a pacifier whenever the baby cries.
- B. Turn on a radio in the room with the baby.
- C. Cuddle and talk to the baby frequently.
- D. Place a brightly colored mobile above the crib.
Correct Answer: C
Rationale: Cuddling and talking foster bonding and emotional development, critical for the infant.
Which nursing action is most appropriate at this time?
- A. Postpone weighing the client until later.
- B. Confront the client about the water intake.
- C. Say nothing and weigh the client as usual.
- D. Subtract 2 lb (0.9 kg) from the client's weight.
Correct Answer: A
Rationale: Postponing weighing ensures accuracy and addresses manipulative behavior.