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A friend says to a nurse, “I am not going to get vaccines for my baby. I hear that vaccines cause autism.” The nurse’s best reply is:
- A. The exact cause of autism is not really known
- B. It’s believed that autism is really a result of birth trauma
- C. There is no conclusive evidence to connect autism to vaccinations.
- D. Please tell me more about where you got that information about autism?
Correct Answer: C
Rationale: This response provides factual, evidence-based information to address the common misconception linking vaccines to autism. It is clear and reassuring for the parent.
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A young woman had just learned of the accidental death of her husband. She begins to cry and states, “It’s not fair! How could he do this to me?” This remark is assessed as:
- A. An explosive episode
- B. An expression of anger
- C. Fear of making decisions alone
- D. A sign of despair.
Correct Answer: B
Rationale: The woman's statement, "It's not fair! How could he do this to me?" expresses a sense of anger and injustice over her husband's accidental death. She is questioning why this has happened to her, which suggests feelings of anger and frustration. This expression is not necessarily a plea for help or a manifestation of fear of making decisions alone, but it is a clear display of anger and a sense of unfairness in the situation.
A 19-year-old patient with undifferentiated schizophrenia is acutely psychotic. The nurse assesses the primary deficit as:
- A. Social isolation
- B. Disturbed thinking
- C. Altered mood states
- D. Poor impulse control
Correct Answer: B
Rationale: Acute psychosis primarily affects thought processes, evidenced by delusions or disorganized thinking.
A novice mental health nurse shares that, “I’ll never get used to playing cards or other games with patients. It seems like a poor use of scarce nursing time.” The best response for the nurse’s mentor would be:
- A. “Perhaps you’ll want to rethink your transfer to this unit if you’re really uncomfortable.”
- B. “Your comments make a point about scarce resources. I’ll ask the treatment team to review our position on activities.”
- C. “Activity co-leadership puts us in a position to help patients develop social skills and support them as they take small risks.”
- D. “Managed care has cost us activities therapists. Activities are
Correct Answer: C
Rationale: The best response for the nurse’s mentor would be to highlight the importance of activities in mental health nursing. Participating in activities such as playing cards or games with patients is not just about passing time, but it also serves a therapeutic purpose. Engaging in activities helps patients to develop social skills, build relationships, and take small risks in a safe environment. As mental health nurses, it is crucial to understand that these activities are not a waste of time but rather an essential part of the therapeutic process. By participating in activities with patients, nurses can actively support their mental well-being and contribute to their overall treatment and recovery.
When leading a therapeutic group, the nurse demonstrates an understanding of the need to act as the group’s executive when:
- A. Restating rules when a new member joins
- B. Being available to orient the new members
- C. Helping a member defuse the anger they are experiencing
- D. Offering personal opinions on group topics
Correct Answer: A
Rationale: When leading a therapeutic group, the nurse's role as the group's executive involves setting and maintaining boundaries, ensuring adherence to the group's rules, and creating a safe and structured environment for all members. Restating rules when a new member joins helps to establish expectations and maintain consistency within the group. It allows the nurse to assert authority and guide the group in a direction that is conducive to therapeutic progress. By upholding the rules and boundaries of the group, the nurse helps to create a sense of safety and trust among the members, allowing for open and productive communication and shared growth.
An advance directive gives legally binding direction for health care interventions when a patient:
- A. Has a new diagnosis of cancer.
- B. Is diagnosed with Parkinson's disease
- C. Diagnosed with amyotrophic lateral sclerosis is unable to speak.
- D. Is unable to make decisions for self because of illness.
Correct Answer: D
Rationale: An advance directive is used when a patient is unable to make their own healthcare decisions, typically due to a serious illness or injury. This legal document outlines the patient’s wishes for treatment and care.