Nokea
When the parents ask if their child is psychotic, the nurse who is performing the initial interview is most correct in explaining which of the following as a behavior exhibited by psychotic people?
- A. They have poor response to new situations.
- B. They have difficulty in relationships.
- C. They cannot differentiate reality from unreality.
- D. They feel helpless in resolving problems.
Correct Answer: C
Rationale: Psychosis is characterized by impaired reality testing.
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If this child is typical of others the same age with a serious illness, which concept is the most commonly held belief about being ill?
- A. Illness is not life-threatening; recovery is assured.
- B. Significant others can prevent serious consequences.
- C. Illness is a punishment for some wrong-doing.
- D. Failure to comply with treatment results in parental rejection.
Correct Answer: C
Rationale: School-age children often view illness as punishment due to magical thinking.
If ruminations about suicide are present, which observation by the nurse is most significant?
- A. The teen is not attending school regularly.
- B. The teen is hoarding sharp objects in the bedroom.
- C. The teen is not completing homework assignments.
- D. The teen is not participating in extracurricular activities.
Correct Answer: B
Rationale: Hoarding sharp objects indicates a high risk for self-harm.
When the client calls the nurse to report the following physical changes, which symptom is considered a serious side effect of clozapine that needs to be reported immediately to the prescribing physician?
- A. Frequent diarrhea
- B. Severe sore throat
- C. Gradual weight loss
- D. Ringing of the ears
Correct Answer: B
Rationale: Severe sore throat may indicate agranulocytosis, a life-threatening side effect of clozapine.
What advice is most appropriate to give the parents at this time?
- A. Tell the parents to disregard their son's behavior; it is normal grieving.
- B. Advise the parents to tell their son to snap out of it; his life is not over.
- C. Suggest transferring their son to another school.
- D. Advise the parents to ask their son about having thoughts of suicide.
Correct Answer: D
Rationale: Directly addressing suicidal thoughts is critical for safety.
Which of the following nursing interventions is most appropriate to include when preparing a care plan for the child in the educational setting?
- A. Work with the teacher to establish clear behavioral expectations for the classroom.
- B. Place a chair in the corner of the room as a potential consequence for poor behavior.
- C. Allow the child to move about the room as desired provided the behavior is not disruptive.
- D. Plan separate learning experiences with more creative assignments and activities.
Correct Answer: A
Rationale: Clear expectations provide structure, beneficial for ADHD management.