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A nurse is assessing a child who has autism spectrum disorder. Which of the following findings should the nurse expect?
- A. Delayed language development
- B. Spinning a toy repetitively
- C. Ritualistic behavior
- D. Consistent limit testing
Correct Answer: A, B, C
Rationale: Delayed language skills, repetitive behaviors, and a need for routines are common in autism spectrum disorder.
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A charge nurse is conducting a staff education in-service about depressive disorders. Which of the following should the nurse identify as a risk factor for depression?
- A. Being married
- B. Pregnancy
- C. Male gender
- D. Chronic illness
Correct Answer: D
Rationale: The correct answer is D: Chronic illness. Chronic illnesses can lead to feelings of hopelessness and helplessness, contributing to the development of depression. Individuals facing long-term health challenges may experience significant emotional distress, impacting their mental health. Other choices are incorrect because being married (A) can provide social support, which is protective against depression; pregnancy (B) can lead to mood changes but is not a consistent risk factor for depression; and male gender (C) does not inherently increase the risk of depression as much as other factors.
A nurse in a mental health clinic is conducting a staff education session on schizophrenia. Which of the following manifestations should the nurse identify as negative symptoms? (Select all that apply.)
- A. Delusions
- B. Hallucinations
- C. Anhedonia
- D. Poor judgment
- E. Blunt affect
Correct Answer: C, E
Rationale: The correct manifestations for negative symptoms of schizophrenia are C: Anhedonia and E: Blunt affect. Anhedonia refers to the inability to feel pleasure, which is a common negative symptom. Blunt affect is a reduction in the range and intensity of emotional expression, another classic negative symptom. Delusions (A) and hallucinations (B) are positive symptoms involving distorted perceptions and beliefs. Poor judgment (D) is a cognitive symptom, not specific to schizophrenia. The absence of options F and G means they are not applicable to this question.
A nurse is caring for a client who has been diagnosed with obsessive-compulsive disorder (OCD) and is constantly picking up after others in the day room. The nurse should recognize that the client uses this behavior to do which of the following?
- A. Limit the amount of time available to interact with others
- B. Focus attention on meaningful tasks
- C. Manipulate and control others’ behaviors
- D. Decrease anxiety to a tolerable level
Correct Answer: D
Rationale: The correct answer is D: Decrease anxiety to a tolerable level. In OCD, repetitive behaviors like picking up after others serve to reduce anxiety stemming from obsessive thoughts. This behavior acts as a coping mechanism to alleviate distress. Choice A is incorrect as the behavior is driven by anxiety, not a desire to limit interaction time. Choice B is incorrect as the behavior is not necessarily meaningful but rather a compulsive act. Choice C is incorrect as the behavior is self-directed, not aimed at controlling others.
A nurse is caring for a 48-year-old client who is grieving following the death of her husband seven months ago. The client reports that she has lost 30 lb and is having difficulty sleeping. Which of the following factors indicate the client is experiencing maladaptive grieving?
- A. The client is 48 years old.
- B. The client's husband died seven months ago.
- C. The client has lost 30 lb.
- D. The client is having difficulty sleeping.
Correct Answer: C
Rationale: The correct answer is C: The client has lost 30 lb. This indicates maladaptive grieving as significant weight loss is a common symptom of unresolved grief. This could be due to appetite changes, neglecting self-care, or depression. Losing a considerable amount of weight can impact physical health and well-being, indicating a need for intervention. Choices A, B, and D are not directly related to maladaptive grieving. Age (A) and the time since the husband's death (B) are not definitive indicators of maladaptive grieving. Difficulty sleeping (D) can be a common symptom of grief but is not as concerning as significant weight loss in this context.
A nurse is caring for a client who has major depressive disorder (MDD). Which of the following findings should the nurse expect?
- A. Significant change in weight
- B. Hyperexcitability
- C. Exaggerated response to stimuli
- D. Attention-seeking behavior
Correct Answer: A
Rationale: The correct answer is A: Significant change in weight. In major depressive disorder (MDD), clients commonly experience appetite changes, leading to weight gain or weight loss. This is due to disturbances in their eating patterns. Weight changes can be a result of decreased interest in food or emotional eating. This is a key symptom to monitor in clients with MDD. Hyperexcitability (B), exaggerated response to stimuli (C), and attention-seeking behavior (D) are not typical findings in clients with MDD. Hyperexcitability and exaggerated response to stimuli are more often associated with conditions like anxiety disorders, while attention-seeking behavior is more commonly seen in personality disorders.