Nokea
The single most common symptom of autism is:
- A. Inability to grasp reality
- B. Impaired social interaction
- C. Acting out behaviors
- D. Diminished affect
Correct Answer: B
Rationale: Though all of these behaviors may occur at some time in autism, impaired social interaction is the overriding symptom that occurs in this disorder.
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A patient receiving risperidone (Risperdal) reports severe muscle stiffness midmorning. During lunch he has difficulty swallowing food and speaking, and when vital signs are taken 30 minutes later, he is noted to be stuporous and diaphoretic, with a temperature of 38.8° C, pulse of 110 beats/min, and blood pressure of 150/90 mm Hg. The nurse should suspect _____ and should _____.
- A. neuroleptic malignant syndrome"¦place him in a cooling blanket and transfer to ICU
- B. anticholinergic toxicity"¦check vital signs and prepare to use a cooling blanket stat
- C. relapse of his psychosis"¦administer PRN antipsychotic drugs and notify his physician
- D. agranulocytosis"¦hold his antipsychotic and draw blood for a complete blood count
Correct Answer: A
Rationale: The correct answer is A: neuroleptic malignant syndrome (NMS). NMS is a rare but serious adverse reaction to antipsychotic medications like risperidone. The patient's symptoms of severe muscle stiffness, difficulty swallowing, altered mental status, diaphoresis, and elevated temperature, pulse, and blood pressure are all consistent with NMS. The nurse should suspect NMS due to the constellation of symptoms and vital sign changes. Placing the patient in a cooling blanket and transferring to the ICU is appropriate as NMS is a medical emergency requiring prompt intervention to lower the body temperature and provide supportive care.
Choices B, C, and D are incorrect:
B: Anticholinergic toxicity does not typically present with the specific symptoms described, such as muscle stiffness and stupor.
C: Relapse of psychosis would not explain the acute onset of symptoms and vital sign changes seen in the scenario.
D: Agranulocytosis is a rare side effect of some ant
An 11-year-old child stays home from school to care for his siblings while his mother works, is demeaned by his father, and has negative self-perceptions. Which indicator would suggest that nursing interventions are succeeding?
- A. The child attends school regularly.
- B. The child is observed playing calmly.
- C. The father rarely speaks during nurse visits.
- D. The mother corrects negative comments by the child.
Correct Answer: A
Rationale: The correct answer is A because regular school attendance indicates the child's improved well-being and ability to prioritize education over caregiving responsibilities.
B: Playing calmly does not necessarily indicate overall improvement in the child's situation.
C: The father's silence during nurse visits does not directly reflect the child's well-being or progress.
D: The mother correcting negative comments by the child is positive but does not directly address the child's caregiving responsibilities or self-perceptions.
Features of schizoid personality include.
- A. Hyper-vigilant ready for real or imagines threat
- B. Inability to respond to others, hyper-vigilant
- C. Social withdrawal, inability to respond to others
- D. Ready for real or imagined threat, social withdrawal
Correct Answer: C
Rationale: Schizoid personality disorder is characterized by social withdrawal and emotional detachment, with little interest in relationships.
An 18-year-old referred to the mental health center often cooks gourmet meals but eats only tiny portions. The patient wears layers of loose clothing saying, "I like the style." The patient's weight dropped from 130 to 95 pounds. She has amenorrhea. Which diagnosis is most likely?
- A. Eating disorder not otherwise specified
- B. Anorexia nervosa
- C. Bulimia nervosa
- D. Binge eating
Correct Answer: B
Rationale: The correct diagnosis is B: Anorexia nervosa. This patient exhibits key symptoms such as restrictive eating leading to significant weight loss, wearing layers of clothing to hide body shape, and amenorrhea. These symptoms align with the diagnostic criteria for anorexia nervosa. The other choices are incorrect because they do not fully capture the combination of symptoms present in this case. Choice A (Eating disorder not otherwise specified) is too broad and does not specify the severity of the symptoms. Choice C (Bulimia nervosa) typically involves binge eating followed by compensatory behaviors, which is not indicated in this case. Choice D (Binge eating) focuses solely on overeating without the restrictive eating and weight loss seen in anorexia nervosa.
A nurse assesses that which of the following individuals is most likely to engage in binge-eating behaviors characteristic of bulimia?
- A. A person who weighs 225 pounds and is 5 feet 4 inches tall.
- B. A person who is 5 pounds overweight and cannot stick to a diet.
- C. A person who lost up 40 pounds but gained it back within 1 year.
- D. A person who monitors caloric intake in order to fit into a small suit.
Correct Answer: B
Rationale: The correct answer is B because binge-eating behaviors are often associated with individuals who struggle to control their eating, leading to episodes of excessive food consumption. Being unable to stick to a diet indicates a lack of control, which is a key characteristic of binge-eating. Choice A focuses more on weight and height, which are not direct indicators of binge-eating. Choice C describes weight fluctuations, which may not necessarily be linked to binge-eating. Choice D emphasizes monitoring caloric intake for a specific goal, which does not necessarily indicate a loss of control over eating behavior.