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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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The desired outcome for a patient experiencing insomnia is, "Patient will sleep for a minimum of 5 hours nightly within 7 days." At the end of 7 days, review of sleep data shows the patient sleeps an average of 4 hours nightly and takes a 2-hour afternoon nap. What is the nurse’s next action?
- A. Continue the current plan without changes.
- B. Remove this nursing diagnosis from the plan of care.
- C. Write a new nursing diagnosis that better reflects the problem.
- D. Examine interventions for possible revision of the target date.
Correct Answer: D
Rationale: When goals are partially met, the plan of care should be re-evaluated, and adjustments should be made to interventions or timelines.
A patient is in a smoking cessation program that encourages self-control therapy interventions. Which intervention would the nurse suggest?
- A. Limiting smoking to certain times of the day
- B. Keeping a behavioral diary that tracks when the patient smokes
- C. Identifying factors that encouraged the patient to start smoking
- D. Making plans to spend money saved when smoking stops
Correct Answer: B
Rationale: Self-control therapy emphasizes self-monitoring to identify triggers and patterns, enabling the patient to implement strategies for behavioral change.
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.
Which complaint is representative of anxiety in a 6-year-old child?
- A. I worry that my dad will get hurt at work.
- B. I get a stomach ache when it's my weekend at my dad's house.
- C. I can't sleep when I stay at Grandma's because I worry about my mom.
- D. I'm not going to sports camp because I don't like being away from my friends.
Correct Answer: B
Rationale: Children often express anxiety through physical complaints like stomachaches, especially in situations that cause distress or discomfort, such as visiting a noncustodial parent.
The treatment team was engaged in planning how group therapy could be included as a part of the structured daily activities of the unit. A new team member asked, “Why is it so important to include group therapy for the patients?” The most accurate response would be based on the assumption that:
- A. Hidden agendas frequently surface in group sessions.
- B. Some persons do not relate well on an individual therapy
- C. Psychopathology has its source in disordered relationships.
- D. Group therapy is far more cost effective for the patients.
Correct Answer: D
Rationale: Group therapy is important because psychopathology often has its roots in disordered relationships. Many mental health issues are influenced by one's interactions with others, whether it be issues with communication, trust, boundaries, or other relational dynamics. Group therapy provides a structured environment where patients can explore and work through these relational difficulties with the support and feedback of peers. By addressing these relational patterns in a group setting, patients can gain insight into their behavior and develop healthier ways of relating to others. This can be a valuable component of their overall treatment plan and can help facilitate lasting change and growth.