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.
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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.
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.
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.
Which assessment finding best indicates that a child taking methylphenidate hydrochloride (Ritalin) is experiencing undesirable side effects?
- A. The child has altered elimination patterns.
- B. The child develops intolerance to certain foods.
- C. The child has an elevated blood pressure.
- D. The child has evidence of skin breakdown.
Correct Answer: C
Rationale: Elevated blood pressure is a concerning side effect of Ritalin.
What is the best suggestion the nurse can give the nursing assistant caring for the 2-year-old child at this time?
- A. Let the child choose from two acceptable alternatives.
- B. Withhold something the child desires until the child complies.
- C. Identify what is expected of the child, rather than ask.
- D. Inform the mother if the child continues to be uncooperative.
Correct Answer: A
Rationale: Offering choices fosters autonomy while maintaining boundaries.
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