Nokea
A 10-year-old boy is diagnosed with gender dysphoria. Which assessment finding would the nurse expect?
- A. Having tea parties with dolls
- B. A compromised sexual response cycle
- C. Identifying with boys who are athletic
- D. Intense urges to watch his parents have sex
Correct Answer: A
Rationale: The correct answer is A because a child with gender dysphoria may display behaviors that align with the gender they identify with, such as engaging in activities typically associated with that gender. Tea parties with dolls may indicate the child's preference for activities stereotypically linked to girls, indicating a mismatch between their assigned gender and gender identity. Choices B, C, and D are incorrect as they do not align with typical assessment findings for gender dysphoria in children. B is more related to sexual dysfunction, C is a common behavior for all children, and D is inappropriate and unrelated to the diagnosis of gender dysphoria.
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A nurse works a rape telephone hotline. Communication should focus on:
- A. Explaining immediate steps victims should take;
- B. Providing callers with a sympathetic listener.
- C. Obtaining information for law enforcement.
- D. Arranging long-term counseling.
Correct Answer: A
Rationale: The correct answer is A because in cases of sexual assault, immediate steps such as seeking medical attention, preserving evidence, and contacting authorities are crucial. Providing sympathy (B) is important but secondary to ensuring victims' safety. Obtaining information for law enforcement (C) should only be done if victims consent, as their safety and well-being are the priority. Long-term counseling (D) is important but not the immediate focus on a hotline call.
In DSM-IV-TR intellectual disabilities are divided into a number of degrees of severity, depending primarily on the range of IQ score provided by the sufferer. One of these is Moderate Mental Retardation, represented by an IQ score between:
- A. 60-65 - to 70-75
- B. 35-40 to 50-55
- C. 80-85 to 90-95
- D. 20-25 to 30-35
Correct Answer: B
Rationale: Moderate Mental Retardation: Defined by DSM-IV-TR as an IQ score between 35-40 to 50-55.
A community mental health nurse is assigned to investigate the frequent school absences of an 11-year-old child. The nurse finds the child home alone, caring for his 1- and 3-year-old siblings. The house is cluttered and dirty, and both parents are at work. The child tells the nurse that whenever his mother is called to work at her part-time job, he must watch the kids because the family cannot afford a babysitter. Based on the information obtained thus far, what preliminary assessment can be made?
- A. The child is coping well with a difficult situation.
- B. The child and his siblings are experiencing neglect.
- C. The children are at high risk for sexual abuse.
- D. The children are experiencing physical abuse.
Correct Answer: B
Rationale: The correct answer is B: The child and his siblings are experiencing neglect. Neglect is defined as failure to provide for a child's basic needs, such as supervision, food, shelter, and medical care. In this scenario, the child is left alone to care for his younger siblings, indicating a lack of appropriate supervision and care from the parents. The house being cluttered and dirty further suggests neglect in terms of living conditions.
Choice A is incorrect because the child is not coping well; rather, he is forced into a caretaker role beyond his developmental capacity. Choice C is incorrect as there is no information provided to suggest sexual abuse. Choice D is incorrect as there is no evidence of physical abuse in the scenario.
When assessing the elderly for depression, the nurse may find that a depressed person over 70 years of age without a medical diagnosis, may have the following symptoms of depression (Select one tha does not apply):
- A. Aches
- B. Pains
- C. Constipation
- D. One-sided weakness
Correct Answer: D
Rationale: These symptoms (A, B, C, E) can be confused with other conditions like electrolyte imbalance or dementia, but are common physical manifestations of depression in the elderly. One-sided weakness (D) is more specific to stroke, not depression.
Which nursing intervention will assist a client being treated in the Emergency Department for extensive soft tissue injuries to disclose an experience of domestic violence?
- A. Interviewing her in the presence of another professional
- B. Speaking with the client in the absence of her husband
- C. Providing a safe, nonintimidating environment
- D. Allowing the client to initiate the topic of violence
Correct Answer: C
Rationale: Rationale for Correct Answer (C): Providing a safe, nonintimidating environment is crucial to encourage the client to disclose domestic violence. This approach helps establish trust and confidentiality, making the client feel secure to share sensitive information. It creates a conducive setting for open communication without fear of repercussions.
Summary of Incorrect Choices:
A: Interviewing her in the presence of another professional may not ensure privacy and could potentially increase the client's discomfort or fear of being overheard.
B: Speaking with the client in the absence of her husband might not guarantee safety and confidentiality, as the client may still feel threatened or hesitant to reveal the abuse.
D: Allowing the client to initiate the topic of violence puts the burden on the client, who may already be feeling overwhelmed or unable to bring up the sensitive issue without support and encouragement.