Nokea
A nurse is assessing a client who has a diagnosis of conversion disorder. Which of the following is an expected finding?
- A. Frequent manic episodes.
- B. Refusal of medication due to paranoia.
- C. Preoccupation with manifestations of various illnesses.
- D. Involuntary loss of a sensory function.
Correct Answer: D
Rationale: The correct answer is D: Involuntary loss of a sensory function. In conversion disorder, physical symptoms are present without a known medical cause. This can manifest as sensory deficits such as blindness or paralysis. This finding is expected as it is a hallmark of conversion disorder. Manic episodes (A) are more indicative of bipolar disorder, medication refusal due to paranoia (B) may be seen in conditions like schizophrenia, and preoccupation with various illnesses (C) is characteristic of somatic symptom disorder. Therefore, the correct choice is D as it aligns with the presentation of conversion disorder.
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A nurse is teaching a newly licensed nurse about reporting suspected child abuse. Which of the following statements indicates an understanding by the newly licensed nurse?
- A. "Evidence must exist prior to reporting."
- B. "If the potential abuser commits to stopping the abuse, health care workers are not required to report it."
- C. "I don't want to defame someone if the report is false."
- D. "If suspicion of abuse exists, then reporting is mandatory."
Correct Answer: D
Rationale: The correct answer is D: "If suspicion of abuse exists, then reporting is mandatory." This statement is correct because as a healthcare professional, it is crucial to report any suspicion of child abuse to protect the child's safety. Reporting is mandatory to ensure that appropriate actions are taken to investigate and prevent harm to the child.
A: "Evidence must exist prior to reporting." - This statement is incorrect because suspicion alone is enough to trigger reporting, and waiting for evidence may delay intervention and put the child at risk.
B: "If the potential abuser commits to stopping the abuse, health care workers are not required to report it." - This statement is incorrect as it is the responsibility of healthcare workers to report suspected abuse regardless of promises made by the potential abuser.
C: "I don't want to defame someone if the report is false." - This statement is incorrect because the focus should be on the safety and well-being of the child, and reporting suspicions of abuse is not about def
A nurse is caring for an adolescent who has a history of violent behavior and has asked the nurse to keep confidential information about the desire to kill several classmates and a school teacher. Which of the following responses by the nurse is appropriate to give?
- A. "Because you are a minor, I have to share any information that I feel is important with your parents."
- B. "I cannot promise that. I must share this information with other members of the team who are responsible for planning your care."
- C. "I will not violate our nurse-client relationship. The information we discuss will remain confidential between us."
- D. "I can see that you trust me, but you should share those feelings with your psychiatrist, not me."
Correct Answer: B
Rationale: Duty to warn applies when a client expresses intent to harm others, requiring disclosure to the care team.
A nurse is performing an admission assessment for a client who is receiving treatment following a situational crisis. Which of the following assessments by the nurse is the highest priority?
- A. Determining if the client has psychotic thinking
- B. Asking the client to identify the cause of the crisis
- C. Identifying the client's coping skills
- D. Identifying the client's support systems
Correct Answer: A
Rationale: The correct answer is A: Determining if the client has psychotic thinking. This is the highest priority because it directly addresses the client's immediate safety and well-being. Psychotic thinking can pose a significant risk to the client and others, requiring prompt intervention. Asking the client to identify the cause of the crisis (B), identifying coping skills (C), and support systems (D) are important but secondary to ensuring the client's safety. It is crucial to address any potential psychotic thinking first before delving into other aspects of the assessment.
A nurse is caring for a client who has autism spectrum disorder. Which of the following findings should the nurse expect?
- A. Expressive affect
- B. Associative looseness
- C. Echolalia
- D. Ambivalence
Correct Answer: C
Rationale: Echolalia, or repeating words/phrases, is a common communication pattern in autism spectrum disorder.
A nurse at a college campus mental health counseling center is caring for a student who just failed an examination. The student spends the session berating the teacher and the course. The nurse should recognize this behavior as which of the following defense mechanisms?
- A. Conversion
- B. Projection
- C. Undoing
- D. Regression
Correct Answer: B
Rationale: Projection involves attributing one’s own feelings or faults to others.