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While engaging in a discussion with a group of teens about risk behaviors, one of the teens says, 'That will never happen to me.' The nurse interprets this as which of the following?
- A. Invincibility fable
- B. Formal operations
- C. Egocentric thinking
- D. Relational aggression
Correct Answer: A
Rationale: The statement reflects the invincibility fable, a common adolescent belief that they are immune to negative consequences. Formal operations refer to cognitive development, egocentric thinking is self-focused but not specific to risk, and relational aggression involves social harm, not denial of risk.
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While caring for a family who lost a 10-year-old son in a car accident, the nurse should instruct the parents to tell the 4-year-old sister which of the following about her brother?
- A. He died and is not coming back.
- B. He passed on to the other side.
- C. He departed on a long journey.
- D. He has gone to see the Lord above.
Correct Answer: A
Rationale: For a 4-year-old, clear, simple language like 'He died and is not coming back' is appropriate to help them understand death without confusion. Euphemisms like 'passed on,' 'long journey,' or 'seeing the Lord' may confuse young children who think concretely and may expect the person to return.
A 3-year-old child has been admitted to the hospital after an automobile accident. Which statement by the nurse would be most appropriate when discussing the type of behavior the parents can expect their child to display while hospitalized?
- A. Your child may not be able to accept how the injury has changed your child?s appearance.
- B. Your child may seem unduly anxious in the presence of strangers.
- C. Your child may experience some guilt feelings associated with the accident.
- D. Your child will exhibit intermittent periodic mood swings, but these should be brief.
Correct Answer: B
Rationale: A 3-year-old is likely to exhibit stranger anxiety, especially in a stressful hospital setting, as they are developmentally prone to fear of unfamiliar people. Appearance concerns, guilt, or mood swings are more typical in older children with greater cognitive awareness.
A nurse is providing care to several chronically ill children. Which of the following would the nurse identify as having the greatest risk for developing a psychiatric problem?
- A. 12 year-old with diabetes mellitus
- B. 5 year-old with cerebral palsy
- C. 8 year-old who has chronic renal disease
- D. 10 year-old with a heart murmur
Correct Answer: C
Rationale: Chronic renal disease in an 8-year-old poses significant physical and emotional stress, including frequent medical interventions and lifestyle restrictions, increasing psychiatric risk. Diabetes and cerebral palsy also carry risks, but renal disease is more invasive, and a heart murmur is typically less severe.
The nurse is counseling a family with a child who has been abused by adult family friend in the past. When explaining about the child?s needs, which of the following would be most important for the nurse to stress?
- A. A supportive relationship with an adult
- B. Long-term psychotherapy
- C. Antidepressant medications
- D. Short-term separation from the parents
Correct Answer: A
Rationale: A supportive relationship with a trusted adult is critical for an abused child?s recovery, providing safety and emotional stability. Long-term psychotherapy or medications may be needed but are secondary, and separation from parents is not indicated unless they are the abusers.
A home-health nurse is working with a poverty-stricken family that has two small children, ages 2 and 3 years. The family lives in an isolated rural area. The family?s home has a dirt floor, and there are chickens living in the house with the family. Because of a recent wind storm, there is a sizeable hole in the roof that lets rain and snow into the house. Which nursing intervention would be the highest priority in this situation?
- A. Make immunization appointments for the children in a nearby town?s public health clinic.
- B. Help the family find funding and manpower to patch and repair the roof of their home.
- C. Determine the educational readiness of the two children.
- D. Report the family for child abuse because of neglect.
Correct Answer: B
Rationale: Repairing the roof is the highest priority to ensure a safe, habitable environment, protecting the children from health risks due to exposure. Immunizations are important but less urgent, educational readiness is secondary, and reporting neglect is premature without assessing intent or resources.