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Questions 164

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Question 1 of 5

A veteran is admitted with a diagnosis of chronic post-traumatic stress disorder. After being placed in the treatment room, he begins to pace frantically and make references to 'highway one.' As the nurse approaches him, he retreats to the corner and sits on the floor with his arms and legs pulled tight to his body. The client is experiencing a:

Correct Answer: D

Rationale: The behavior and reference to 'highway one' suggest a flashback, where the client is reliving a traumatic event, common in PTSD.

Question 2 of 5

The nurse is performing a developmental assessment on a 12-month-old client. Which of the following findings are expected at this age? Select all that apply.

Correct Answer: A,B,D

Rationale: By 12 months, infants typically triple birth weight, cruise along furniture, and search for hidden objects (object permanence). Kicking a ball and two-word phrases are expected at 18-24 months.

Question 3 of 5

A woman in a residence facility is having difficulty sleeping at night. Which action by the nurse is most appropriate initially?

Correct Answer: B

Rationale: A back rub and warm milk promote relaxation non-pharmacologically, addressing insomnia safely. Medication, walking, or tea (caffeine) are less appropriate.

Question 4 of 5

A 6-month old is brought to the ER by her mother. During the assessment, the nurse finds multiple bruises in different stages of healing and decreased range of motion of the right leg. X-ray confirms a fracture of the right femur. Which statement made by the mother would contribute to a diagnosis of child abuse?

Correct Answer: C

Rationale: The mother's inability to recall any injury event, combined with multiple bruises and a femur fracture, raises suspicion of child abuse due to inconsistent history.

Question 5 of 5

A father suspected of child abuse tells the nurse, 'I shouldn't have grabbed him so hard. I had a really bad day at work and got all stressed out. The kid just wouldn't listen to me.' The defense mechanism used by the father is:

Correct Answer: B

Rationale: Displacement involves redirecting emotions (stress from work) onto a less threatening target (child). Projection, undoing, and compensation do not apply.

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