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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.
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To help the parents cope with their disappointment and loss of their 'perfect' baby, which nursing action is most appropriate initially?
- A. Encourage the parents to verbalize their feelings.
- B. Treat the child as a normal newborn.
- C. Refer the couple to community resources for assistance.
- D. Encourage the parents to consider long-term institutional placement.
Correct Answer: A
Rationale: Encouraging verbalization allows parents to express grief and begin processing their emotions, which is critical initially for coping with the diagnosis.
If this diagnosis is accurate, it is most important for the nurse to assess for which characteristic finding?
- A. The mother is obsessed with the fear that her child will die.
- B. The mother is well versed in normal health patterns among children.
- C. The mother is responsible for creating the child's symptoms.
- D. The mother is overreacting to minor variations in her child's health.
Correct Answer: C
Rationale: Munchausen syndrome by proxy involves a caregiver causing or fabricating symptoms.
After conferring with the nurse, which response by the receptionist to the mother is most appropriate at this time?
- A. The clinic cannot release that information.
- B. Your daughter will return the phone call shortly.
- C. You may talk to your daughter after her examination.
- D. Your daughter came to the clinic for birth control.
Correct Answer: A
Rationale: Confidentiality protects the teen's privacy, especially for reproductive health.
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 nursing action is most appropriate for the mother at this time?
- A. Briefly take over bathing the newborn.
- B. Advise the mother to discontinue the bath.
- C. Give all future baths in the nursery.
- D. Point out the good job being done.
Correct Answer: A
Rationale: Taking over briefly supports the mother, reducing her anxiety while allowing her to remain involved.