Answer to Question 1
Correct Answer: 2
Observation of the interaction between the child and mother can provide information suggestive of child abuse. The mother's demonstration of disgust with any aspect of child's behavior or such things as odor or stool can be clues that there may be a problem with the relationship and should be evaluated further. The loose stool may be a sign of illness; however, there is not enough information to determine if the child is ill; may be the result of the child's diet; or may be a sign of illness; however, there is not enough information to determine if the child is ill, and the mother's response is inappropriate
Answer to Question 2
Correct Answer: 1, 2, 4
The way a client dresses and maintains physical hygiene may provide clues to a variety of things, such as what the client does for a living (perhaps the client has a physical job and has just come from work), the client's sense of self-esteem and body image, as well as be an indicator of mental illness, anxiety, or depression. The client's disheveled appearance does not directly clue the nurse to explore the client's smoking history. Clues that would lead the nurse to fully explore the client's smoking history would include the smell of smoke on the client, the discoloration of the fingers from tobacco, hoarseness of the voice, and/or a cough. The observations made by the nurse do not clue the nurse to assess the client's immunization status.