Nokea
A nurse is reviewing the history and physical of an adolescent client diagnosed with conduct disorder. The nurse recognizes that which of the following is an expected assessment finding of conduct disorder?
- A. Death of client's father two months ago
- B. Experiences frequent facial tics
- C. Adheres strictly to routines
- D. Suspended from school several times in the past year
Correct Answer: D
Rationale: The correct answer is D: Suspended from school several times in the past year. Conduct disorder is characterized by persistent patterns of behavior that violate the rights of others and societal norms. Being suspended from school multiple times indicates a disregard for rules and authority, which is a common feature of conduct disorder. Choices A, B, and C do not directly align with the typical behaviors associated with conduct disorder. A recent death in the family (A) may lead to emotional distress but is not a defining characteristic of conduct disorder. Frequent facial tics (B) are more indicative of a neurological or psychological condition, not conduct disorder. Adhering strictly to routines (C) is more characteristic of obsessive-compulsive disorder, not conduct disorder.
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A nurse is talking with a client diagnosed with schizophrenia. Suddenly the client states,I'm frightened. Do you hear that? The voices are telling me to do terrible things. Which of the following responses by the nurse is appropriate?
- A. What are the voices telling you to do?
- B. You need to tell the voices to leave you alone.
- C. You need to understand that there are no voices.
- D. Why do you think you are hearing the voices?
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. **Acknowledge the client's experience**: By asking "What are the voices telling you to do?" the nurse validates the client's experience and shows empathy.
2. **Encourages communication**: This response opens up a dialogue and allows the nurse to gather more information for assessment and understanding.
3. **Avoids dismissing or denying the experience**: Options B and C dismiss or deny the existence of the voices, which can make the client feel unheard or misunderstood.
4. **Promotes therapeutic communication**: Asking about the content of the voices helps the nurse assess the client's level of distress and potential risk.
5. **Supports building trust**: By demonstrating active listening and showing interest in the client's experience, the nurse can build a trusting therapeutic relationship.
Summary:
- Option A is correct as it acknowledges the client's experience and promotes communication.
- Options B and C dismiss or deny the client's experience.
- Option D focuses on the cause rather
A nurse is teaching a newly licensed nurse about heparin-induced thrombocytopenia. Which of the following risk factors for this disorder should the nurse include in the teaching?
- A. Systemic lupus erythematosus
- B. Placental abruption
- C. Heparin therapy for deep-vein thrombosis
- D. Warfarin therapy for atrial fibrillation
Correct Answer: C
Rationale: Rationale: Heparin-induced thrombocytopenia (HIT) is a rare but serious complication of heparin therapy, causing a drop in platelet count. The correct answer is C because heparin therapy for deep-vein thrombosis is a known risk factor for HIT. Systemic lupus erythematosus (choice A) is associated with other complications but not specifically HIT. Placental abruption (choice B) is a condition related to pregnancy complications. Warfarin therapy for atrial fibrillation (choice D) is not a risk factor for HIT. Therefore, the nurse should focus on heparin therapy as a significant risk factor in HIT education.
A nurse has received a report on a group of clients. Which of the following client clients should the nurse assess first?
- A. A client who has type 2 diabetes mellitus has a blood glucose level of 120 mg/dL (74 - 106 mg/dL)
- B. A client who has diabetes insipidus has an intake of 1,500 mL and an output of 1,600 mL in 24 hr.
- C. A client who has Graves' disease has a heart rate of 100/min and reports tremors.
- D. A client who has a left-sided stroke reports severe headache and is manifesting confusion.
Correct Answer: D
Rationale: The correct answer is D. A client with a left-sided stroke reporting severe headache and confusion should be assessed first due to the potential risk of worsening neurological status. Headache and confusion could indicate a worsening condition such as hemorrhage or increased intracranial pressure, requiring immediate intervention to prevent further damage. Assessing this client first allows for prompt treatment and prevention of complications. Choices A, B, and C involve clients with chronic conditions or stable vital signs that do not indicate immediate danger. Assessing the client with a left-sided stroke takes priority over these cases due to the acute nature of the symptoms.
A nurse is talking with the guardian of a school-aged child recently diagnosed with intermittent explosive disorder (IED). The guardian says,My child is impulsive, acts out aggressively, and then seems pleased with themselves. How can my child be happy? Which of the following responses should the nurse make?
- A. Appearing pleased after an aggressive or impulsive act has not been directly linked to intermittent explosive disorder.
- B. Appearing pleased after an aggressive or impulsive act can be a sense of relief rather than being happy.
- C. Appearing pleased after an aggressive or impulsive act is a manifestation of lack of empathy or compassion.
- D. Appearing pleased after an aggressive or impulsive act is within the control of your child.
Correct Answer: B
Rationale: Correct Answer: B
Rationale: The nurse should choose response B because it addresses the guardian's concern accurately. Individuals with intermittent explosive disorder may experience a sense of relief rather than genuine happiness after acting out aggressively. This relief can stem from a temporary release of pent-up emotions or stress. It is important for the nurse to clarify this distinction to the guardian to help them understand their child's behavior better and guide appropriate interventions.
Incorrect Choices:
A: This response dismisses the guardian's observations and does not provide a helpful explanation.
C: This response inaccurately suggests a lack of empathy or compassion, which is not a defining characteristic of intermittent explosive disorder.
D: This response implies that the behavior is under the child's control, which is not necessarily the case with impulsive disorders like IED.
A nurse is creating a plan of care for a client who is experiencing mania. Which of the following interventions should the nurse include in the plan? (Select all that apply.)
- A. Weigh the client every 3 to 4 days.
- B. Discourage the client from taking a nap during the day.
- C. Monitor vital signs throughout the day.
- D. Offer nutritional foods to the client every 2 hours.
- E. Maintain an environment with low stimuli.
Correct Answer: B,C,D,E
Rationale: The correct interventions are B, C, D, and E. B: Discouraging naps helps regulate sleep patterns in mania. C: Monitoring vital signs is crucial due to potential physical risks. D: Offering frequent, nutritional foods helps stabilize energy levels. E: Low-stimuli environment reduces agitation. A is incorrect as frequent weighing may not be necessary. F and G are not provided but would be incorrect if they do not align with managing mania symptoms.