The nurse is assessing a 4-year-old child with a possible alteration in mental health. Which findings indicate a need for further investigation? Select all that apply
1. Fails to make eye contact
2. Flinches when touched on the arm
3. History of limited prenatal care and precipitate delivery
4. Head circumference has not changed in over 1 year
5. Flat facial expressions
1, 2, 3, 5
Explanation:
1. Making eye contact with the nurse and caregiver is part of the child's overall affect and social skills. A child who fails to make eye contact may have an alteration in mental health.
2. Flinching may indicate a desire to avoid contact; this can indicate a mental health issue and should be further evaluated.
3. History of prenatal care and delivery can help determine potential alterations in mental health in a child.
4. Head circumference is not measured in a 4-year-old.
5. Affect can be determined by facial expression and response to the nurse, helping to determine mental health.
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