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A nurse is planning care for a client who has dependent personality disorder. Which of the following actions should the nurse plan to take?
- A. Monitor the client closely to prevent self-mutilation.
- B. Set limits to prevent exploitation of other clients.
- C. Give positive feedback when the client is assertive with staff or clients.
- D. Discourage flamboyant or seductive behaviors.
Correct Answer: C
Rationale: The correct answer is C: Give positive feedback when the client is assertive with staff or clients. This is because individuals with dependent personality disorder often struggle with low self-esteem and lack of confidence in their own abilities. By providing positive feedback when the client demonstrates assertiveness, the nurse can reinforce and encourage this behavior, ultimately promoting the client's independence and self-confidence.
Choice A is incorrect because monitoring for self-mutilation is more relevant for clients with other mental health disorders such as borderline personality disorder. Choice B is incorrect as setting limits to prevent exploitation is more appropriate for clients with antisocial personality disorder. Choice D is incorrect as discouraging flamboyant or seductive behaviors is more relevant for clients with histrionic personality disorder.
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A nurse is caring for a client who requires a crisis intervention for acute anxiety. Which of the following nursing actions is the highest priority?
- A. Determining the cause of the client's anxiety
- B. Identifying the client's coping skills
- C. Protecting the client from injury to himself
- D. Ensuring that the client feels safe
Correct Answer: C
Rationale: The correct answer is C: Protecting the client from injury to himself. This is the highest priority because during a crisis intervention for acute anxiety, the client may be at risk of harming themselves. Ensuring their safety is crucial before addressing other needs. Option A is important but not the highest priority in this acute situation. Option B is relevant but not as urgent as ensuring safety. Option D is also important, but physical safety takes precedence over emotional safety.
Which of the following is a characteristic sign of hyperthyroidism?
- A. Cold intolerance
- B. Fatigue and lethargy
- C. Tremors and nervousness
- D. Weight gain
Correct Answer: C
Rationale: The correct answer is C: Tremors and nervousness. Hyperthyroidism is an overactive thyroid gland leading to an excess of thyroid hormones. Tremors and nervousness are classic symptoms due to the increased metabolic rate. Cold intolerance (A) is a symptom of hypothyroidism, not hyperthyroidism. Fatigue and lethargy (B) are common in hypothyroidism, not hyperthyroidism. Weight gain (D) is also more indicative of hypothyroidism. Therefore, the presence of tremors and nervousness (C) is the characteristic sign of hyperthyroidism.
A nurse is assessing a child. The nurse should identify which of the following findings puts the child at risk for the development of conduct disorder?
- A. The child was not promoted to the next grade.
- B. The child moved to three new homes over a two-year period.
- C. The child's best friend was absent from the child's birthday party.
- D. The child has been raised by a parent who has recurrent major depressive disorder.
Correct Answer: D
Rationale: The correct answer is D, as a child raised by a parent with major depressive disorder is at risk for conduct disorder due to the potential lack of emotional support, inconsistent parenting, and exposure to negative behaviors. This can lead to the child developing conduct issues. Choices A, B, and C do not directly correlate with the development of conduct disorder as they do not involve a significant risk factor like living with a parent with major depressive disorder.
The nurse in the emergency room is reviewing the health record of a client who is being evaluated for Graves' disease. Which of the following laboratory results is an expected finding?
- A. Decreased thyrotropin receptor antibodies
- B. Decreased free thyroxine index
- C. Decreased triiodothyronine
- D. Decreased thyroid-stimulating hormone (TSH)
Correct Answer: D
Rationale: The correct answer is D: Decreased thyroid-stimulating hormone (TSH). In Graves' disease, there is excessive production of thyroid hormones, leading to negative feedback on the pituitary gland, resulting in decreased TSH levels. This is because the elevated thyroid hormone levels signal the pituitary gland to decrease TSH production.
A: Decreased thyrotropin receptor antibodies - This is incorrect as Graves' disease is associated with increased levels of these antibodies.
B: Decreased free thyroxine index - This is incorrect as Graves' disease typically presents with elevated levels of free thyroxine.
C: Decreased triiodothyronine - This is incorrect as Graves' disease is characterized by elevated levels of triiodothyronine due to increased thyroid hormone production.
In summary, the expected finding in Graves' disease is a decreased TSH level due to the negative feedback mechanism, making option D the correct choice.
A nurse is planning care for a client who has hyperthyroidism and is receiving radioactive iodine (radioiodine). Which of the following statements by the nurse regarding special precautions is appropriate?
- A. You will need to use a bathroom separate from other household members.
- B. You will need to remain at the hospital for the entire time the radioiodine is radioactive.
- C. A low fiber diet will be necessary.
- D. Additional Immunizations will be needed for full protection.
Correct Answer: A
Rationale: Rationale: Choice A is correct because radioiodine is excreted through bodily fluids including urine. Using a separate bathroom prevents exposure to others. Choice B is incorrect as hospitalization isn't always required. Choice C is irrelevant to radioiodine therapy. Choice D is incorrect as immunizations are not directly related to radioiodine precautions.