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To establish a good interview relationship with an adolescent, which strategy is most
appropriate?
1. Asking personal questions unrelated to the situation
2. Writing down everything the teen says
3. Asking open-ended questions
4. Discussing the nurse's own thoughts and feelings about the situation - Correct Answers-3.
Asking open-ended questions
RATIONALE: Open-ended questions allow the adolescent to share information and feelings.
Asking personal questions not related to the situation jeopardizes the trust that must be
established because the adolescent may feel as though he's being interrogated with
unnecessary questions. Writing everything down during the interview can be a distraction and
doesn't allow the nurse to observe how the adolescent behaves. Discussing the nurse's
thoughts and feelings may bias the assessment and is inappropriate when interviewing any
client
A chronically ill school-age child is most vulnerable to which stressor?
1. Mutilation anxiety
2. Anticipatory grief
3. Anxiety over school absences
,4. Fear of hospital procedures - Correct Answers-3. Anxiety over school absences
RATIONALE: The school-age child is becoming industrious and attempts to master school-related
activities. Therefore, school absences are likely to cause extreme anxiety for a school-age child
who's chronically ill. Mutilation anxiety is more common in adolescents. Anticipatory grief is
rare in a school-age child. Fear of hospital procedures is most pronounced in preschool-age
children.
When developing a care plan for an adolescent, the nurse considers the child's psychosocial
needs. During adolescence, psychosocial development focuses on:
1. becoming industrious.
2. establishing an identity.
3. achieving intimacy.
4. developing initiative. - Correct Answers-2. establishing an identity.
RATIONALE: According to Erikson, the primary psychosocial task during adolescence is to
establish a personal identity while overcoming role or identity confusion. The adolescent
attempts to establish a group identity by seeking acceptance and approval from peers, and
strives to attain a personal identity by becoming more independent from his family. Becoming
industrious is the developmental task of the school-age child; achieving intimacy is the task of
the young adult; and developing initiative is the task of the preschooler.
A nurse notes that an infant develops arm movement before fine-motor finger skills and
interprets this as an example of which pattern of development?
1. Cephalocaudal
2. Proximodistal
3. Differentiation
, 4. Mass-to-specific - Correct Answers-2. Proximodistal
RATIONALE: Proximodistal development progresses from the center of the body to the
extremities, such as from the arm to the fingers. Cephalocaudal development occurs along the
body's long axis; for example, the infant develops control over the head, mouth, and eye
movements before the upper body, torso, and legs. Mass-to-specific development, sometimes
called differentiation, occurs as the child masters simple operations before complex functions
and moves from broad, general patterns of behavior to more refined ones.
A teenage mother brings her 1-year-old child to the pediatrician's office for a well-baby
checkup. She says that her infant can't sit alone or roll over. An appropriate response by the
nurse would be:
1. "This is very abnormal. Your child must be sick."
2. "Let's see about further developmental testing."
3. "Don't worry, this is normal for her age."
4. "Maybe you just haven't seen her do it." - Correct Answers-. "Let's see about further
developmental testing."
RATIONALE: Stating that further developmental testing is necessary is appropriate because at
age 12 months a child should be sitting up and rolling over. Therefore, this child may have
developmental problems. Saying the infant's behavior is abnormal or suggesting that the
mother hasn't seen her infant do these milestones isn't therapeutic and can cut off
communication with the mother. Telling the mother that the infant's behavior is normal
misleads the mother with false reassurance.
The mother of an 11-month-old infant reports to the nurse that her infant sleeps much less than
other children. The mother asks the nurse whether her infant is getting sufficient sleep. What
should be the nurse's initial response?
1. Reassure the mother that each infant's sleep needs are individual.