Nokea
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.
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A nurse is caring for an adolescent client who has a new diagnosis of schizophrenia. The client's parents are tearful and express feelings of guilt. Which of the following statements should the nurse make?
- A. "You said that you feel guilty about your daughter's diagnosis. Let's talk about what is causing you to feel this way."
- B. "You should not feel guilty about your daughter's diagnosis. Schizophrenia is unpreventable."
- C. "I’m sure your daughter’s diagnosis is very difficult to deal with, but everything will be all right once she receives the proper treatment."
- D. "Your provider has explained the causes of schizophrenia. Why do you feel guilty about your daughter's diagnosis?"
Correct Answer: A
Rationale: Encouraging the parents to discuss their feelings helps with emotional processing and coping.
A nurse in an acute care facility is admitting an older adult client who has dementia due to Alzheimer's disease. The nurse notes that the client's partner appears exhausted. He states that he is finding it more and more difficult to care for his wife. Which of the following interventions is the nurse’s priority?
- A. Recommend that the partner place the client in a long-term care facility.
- B. Suggest that the partner see a counselor to help him cope with his exhaustion.
- C. Ask the partner to talk about his difficulties in caring for the client.
- D. Tell the partner to call a family meeting to get help.
Correct Answer: C
Rationale: Rationale: The correct answer is C - Ask the partner to talk about his difficulties in caring for the client. This is the priority intervention as it allows the nurse to assess the partner's needs, provide emotional support, and gather information to develop a plan for support. By actively listening to the partner's concerns, the nurse can address immediate issues and provide resources for assistance. Other options (A) recommending long-term care, (B) suggesting counseling, and (D) calling a family meeting are important but not the priority as they do not directly address the partner's immediate emotional and practical needs. It is essential to prioritize addressing the partner's exhaustion and emotional well-being to ensure holistic care for both the client with dementia and their caregiver.
A nurse is caring for a client following a recent suicide attempt. Which of the following actions should the nurse take?
- A. Place metal utensils on the client’s meal tray
- B. Assign the client to a private room
- C. Inspect the client's personal belongings
- D. Tuck bedcovers over the client’s hands and arms
Correct Answer: C
Rationale: The correct answer is C: Inspect the client's personal belongings. This action is crucial to ensure the safety of the client by identifying any potentially harmful items that could be used for another suicide attempt. Placing metal utensils (A) on the tray could pose a risk. Assigning to a private room (B) may isolate the client further. Tucking bedcovers (D) could restrict movement. Other choices are not relevant.
A nurse is caring for a client who has bipolar disorder and is in the manic phase. The client says he is bored. Which of the following activities is appropriate for the nurse to suggest to this client?
- A. Watching a video with a group in the day room
- B. Walking with the nurse in the courtyard
- C. Participating in a basketball game in the gym
- D. Joining a group discussion about a local election
Correct Answer: B
Rationale: The correct answer is B: Walking with the nurse in the courtyard. During the manic phase, individuals with bipolar disorder may have high energy levels and increased impulsivity. Walking in the courtyard with the nurse provides a safe outlet for physical activity and helps to channel excess energy in a constructive manner. This activity also allows for one-on-one interaction, which can help the client focus and reduce boredom. Other options like watching a video with a group or participating in a basketball game may be too stimulating and could exacerbate manic symptoms. Joining a group discussion about a local election might be overwhelming and less effective in managing the client's energy level and attention.
A nurse is caring for a new client who exhibits manifestations of a major depressive episode. The provider states that she wants to rule out medical conditions that could also be linked to the findings. The nurse should expect diagnostic testing for which of the following medical conditions?
- A. Pancreatitis
- B. Cholecystitis
- C. Tuberculosis
- D. Hypothyroidism
Correct Answer: D
Rationale: The correct answer is D: Hypothyroidism. Major depressive episodes can be a symptom of hypothyroidism due to the impact of thyroid hormones on mood regulation. Diagnostic testing for hypothyroidism typically includes measuring levels of thyroid-stimulating hormone (TSH) and free thyroxine (T4). Pancreatitis (A) and cholecystitis (B) are conditions primarily related to the gastrointestinal system and do not typically present with depressive symptoms. Tuberculosis (C) is an infectious disease affecting the lungs and other organs, but it does not directly cause major depressive episodes. Therefore, ruling out hypothyroidism through diagnostic testing is the most relevant in this case.