A 26-month-old child displays many negative behaviors. The parent says, "My child refuses toilet training and shouts, 'No, no, no!' when given directions. What do you think is wrong?" Select the registered nurse's best reply:
Select one:

The child needs more control. You have been weak."

Some undesirable attitudes are developing at this time. A child psychologist can help you develop a remedial plan.

This is normal for your child's age. The child is striving for independence."

"There may be developmental problems. Most children are toilet trained by age 2 years and a half.

Answer and Explanation

The Correct Answer is C

The child is striving for independence.” The behaviors described by the parent are typical for a child who is 26 months old. At this age, children are beginning to develop a sense of autonomy and independence, and they may resist direction and assert their own will. Toilet training can also be a challenging process for both children and parents, and it is not uncommon for children to resist or refuse toilet training at first.

Option a. “The child needs more control. You have been weak” is not a helpful response because it places blame on the parent and does not provide any useful information or guidance.

Option b. “Some undesirable attitudes are developing currently. A child psychologist can help you develop a remedial plan” may be an appropriate response if the child’s behaviors were significantly outside the norm for their age or if they were causing significant distress or disruption. However, based on the information provided by the parent, this does not appear to be the case.

Option d. “There may be developmental problems. Most children are toilet trained by age 2 years and a half” is not a helpful response because it may cause unnecessary worry or concern for the parent. While many children are toilet trained by age 2 and a half, there is a wide range of normal variation in when children achieve this milestone.

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Correct Answer is D

Explanation

During a crisis, the client may be at risk of harming themselves or others. The nurse should take steps to ensure the safety of the client and those around them. Once the immediate safety concerns have been addressed, the nurse can then focus on identifying the cause of the client’s anxiety and helping them develop coping skills.

A. A client who recently burned her arm by accident while using a hot iron at home. B. A client who tells the nurse he experienced manifestations of severe anxiety before and during a job interview. C. A client who requests that her antipsychotic medication be changed due to some new adverse eﬀects. D. A client that says he is hearing a voice that tells him he is not worthy of living anymore.

Correct Answer is D

Explanation

This client is experiencing auditory hallucinations and may be at risk for self-harm or suicide. The nurse should prioritize visiting this client first to assess their safety and provide appropriate interventions.

Option a. A client who recently burned her arm by accident while using a hot iron at home may require wound care and education on safety, but this situation is not as urgent as the client experiencing auditory hallucinations.

Option b. A client who tells the nurse he experienced manifestations of severe anxiety before and during a job interview may benefit from interventions to manage anxiety, but this situation is not as urgent as the client experiencing auditory hallucinations.

Option c. A client who requests that her antipsychotic medication be changed due to some new adverse eﬀects may require medication adjustment and monitoring for side eﬀects, but this situation is not as urgent as the client experiencing auditory hallucinations.

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A 26-month-old child displays many negative behaviors. The parent says, "My child refuses toilet training and shouts, 'No, no, no!' when given directions. What do you think is wrong?" Select the registered nurse's best reply: Select one:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a who requires a crisis intervention for acute anxiety. Which of the following actions is the highest priority?

Correct Answer is D

Explanation

A nurse is caring for several clients who are attending community-based mental health programs. Which Of the following clients should the nurse plan to visit first? Select one:

Correct Answer is D

Explanation

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A 26-month-old child displays many negative behaviors. The parent says, "My child refuses toilet training and shouts, 'No, no, no!' when given directions. What do you think is wrong?" Select the registered nurse's best reply:
Select one: