Nokea
Which statement is most concerning regarding a depressed client's state of mind?
- A. I just want to go to sleep and not wake up.'
- B. When I get out of here I'm going to kill myself.'
- C. I'm so tired of living like this; I want it to be over.'
- D. Shooting myself with dad's gun will end it all quickly.'
Correct Answer: D
Rationale: The correct answer is D because it specifically mentions a method of suicide involving a gun, indicating a higher level of planning and immediacy. This statement suggests a clear intent to harm oneself and poses an immediate risk. Choice A expresses a desire to escape but lacks a specific plan. Choice B indicates a future intent, which may not necessarily pose an immediate risk. Choice C expresses a desire for the suffering to end but does not specify a method, indicating a lower level of immediate risk compared to choice D.
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The nurse is contributing to a teaching plan. What information should the nurse include that identifies the methods in which HIV can be transmitted? (Select all that apply.)
- A. Urine
- B. Sweat
- C. Saliva
- D. Semen
Correct Answer: D
Rationale: Step 1: HIV is primarily transmitted through body fluids containing high concentrations of the virus, such as semen.
Step 2: Semen contains a high viral load, making it a common mode of HIV transmission.
Step 3: Other body fluids like urine, sweat, and saliva do not typically contain high enough levels of the virus to transmit HIV.
Step 4: Therefore, option D (Semen) is correct as it aligns with the established modes of HIV transmission.
Summary: Urine, sweat, and saliva do not pose a significant risk for HIV transmission due to their low viral load. Semen, on the other hand, contains high concentrations of the virus, making it a primary mode of transmission.
Common Level 2 issues typically include...
- A. Triangles, alliances and boundaries
- B. Marital conflict, alcoholism, or gambling
- C. Inner conflicts, problems with intimacy
- D. Executive capacity issues
Correct Answer: B
Rationale: Level 2 families typically struggle with relational dynamics such as marital conflict or substance abuse, which disrupt family functioning beyond basic survival needs.
A patient admitted yesterday for injuries sustained in a fall while intoxicated believes bugs are crawling on the bed. The patient is anxious, agitated, and diaphoretic. What is the priority nursing diagnosis?
- A. Ineffective airway clearance
- B. Ineffective coping
- C. Ineffective denial
- D. Risk for injury
Correct Answer: D
Rationale: The correct answer is D: Risk for injury. This is the priority nursing diagnosis because the patient's current state of agitation and anxiety, coupled with the belief of bugs crawling on the bed, poses an immediate risk for self-injury. The patient's altered mental status and intoxication increase the likelihood of accidental harm.
Explanation for other choices:
A: Ineffective airway clearance - While this is always a critical concern, the patient's current presentation does not indicate any immediate threat to the airway.
B: Ineffective coping - While the patient may be experiencing distress, the primary focus should be on addressing the risk of injury given the patient's altered mental status.
C: Ineffective denial - While the patient may be experiencing hallucinations, the primary concern is the risk of injury rather than the patient's denial of the situation.
The theorist associated with zone of proximal development is
- A. Jean Piaget
- B. Erik Erikson
- C. Lev Vygotsky
- D. John Dewey
Correct Answer: C
Rationale: Vygotsky's zone of proximal development defines learning potential with guidance.
The theorist who believes in moral reasoning is
- A. Sigmund Freud
- B. Lawrence Kohlberg
- C. Abraham Maslow
- D. Erik Erikson
Correct Answer: B
Rationale: Lawrence Kohlberg's stages of moral reasoning build on cognitive development.