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.
You might also like to view...
An immunocompromised child has been exposed to chickenpox. What should the nurse anticipate to be prescribed to the exposed child?
a. Acyclovir (Zovirax) b. Valacyclovir (Valtrex) c. Amantadine (Symmetrel) d. Varicella-zoster immune globulin
The family of a mechanically ventilated client receiving a chest tube asks why the tube is necessary. The nurse responds:
1. "The chest tube helps to decompress the lung and prevents further complications.". 2. "The chest tube helps the client breathe more easily when on a ventilator.". 3. "The chest tube is an elective procedure that many health care providers like to perform.". 4. "The chest tube requires the client to go to surgery for placement.".
The faculty member explains to students that the Omaha Problem Classification system
a. classifies problems based on their severity. b. is designed for community health nursing. c. helps nurses allocate resources in home health. d. is the most complete nursing nomenclature system.
A nurse is teaching relaxation and controlled breathing to a group of survivors of domestic sexual violence. Learning these skills will help survivors to: Select all that apply
A) Find the strength to forgive themselves for what happened. B) Reduce the frequency of flashbacks. C) Manage anxiety attacks. D) Find the strength to confront their abusers. E) Return to a safe place in their minds.