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A nurse observes a patient who is sitting alone in a room put hands over both ears and vigorously shake her head as though saying, 'No.' Later the patient cries and mutters, 'You don't know what you're talking about! Leave me alone.' What assessment should the nurse attempt to validate?
- A. The patient is seeking the attention of staff.
- B. The patient is inappropriately expressing emotion.
- C. The patient is experiencing auditory hallucinations.
- D. The patient is displaying negative symptoms of schizophrenia.
Correct Answer: C
Rationale: The correct answer is C because the patient's behavior indicates a possible experience of auditory hallucinations. The patient covering both ears and shaking her head could be an attempt to block out voices or sounds she is hearing. The subsequent crying and muttering could be a response to these hallucinations.
Choice A is incorrect because the patient's behavior does not necessarily indicate a desire for attention. Choice B is incorrect because the patient's emotional expression is not the primary focus of the behavior. Choice D is incorrect because negative symptoms of schizophrenia typically involve a decrease in emotional expression or motivation, which is not evident in this scenario.
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A patient with schizophrenia repeatedly asks for directions and the time of day. The nurse should:
- A. repeat the information in a kind, matter-of-fact manner.
- B. write out the information so the patient can easily refer to it.
- C. tell the patient that the habit of frequent questioning is annoying.
- D. provide the information once and then remind the patient that the question was already asked.
Correct Answer: A
Rationale: The correct answer is A because patients with schizophrenia may have cognitive impairments affecting memory and orientation, leading to repetitive questioning. By repeating information in a kind, matter-of-fact manner, the nurse can address the patient's needs without causing distress.
Choice B may be helpful, but verbal reinforcement is essential for immediate clarification. Choice C is incorrect as it may exacerbate the patient's distress and worsen the therapeutic relationship. Choice D does not address the underlying cognitive issue and may come across as dismissive.
While performing an assessment, the nurse says to a patient, 'While growing up, most of us heard some half-truths about sexual matters that continue to puzzle us as adults. Do any come to your mind now?' The purpose of this question is to
- A. identify areas of sexual dysfunction for treatment.
- B. determine possible homosexual urges.
- C. introduce the topic of masturbation.
- D. identify sexual misinformation.
Correct Answer: D
Rationale: The correct answer is D: identify sexual misinformation. The nurse's question aims to uncover any misconceptions or false information the patient may have received about sexual matters in the past. By identifying these misinformation, the nurse can address and correct them to promote the patient's sexual health and well-being.
Explanation:
1. The nurse's question specifically targets the patient's recollection of "half-truths about sexual matters," indicating a focus on misinformation.
2. By asking the patient if any of these half-truths still puzzle them as adults, the nurse seeks to identify areas where the patient may have received incorrect information.
3. Addressing sexual misinformation is crucial for promoting accurate knowledge, healthy attitudes, and behaviors related to sexuality.
Summary:
A: Incorrect. The question does not directly aim to identify areas of sexual dysfunction for treatment.
B: Incorrect. The question does not target determining possible homosexual urges but rather focuses on uncovering sexual misinformation.
C: Incorrect. The question does not introduce the
An Arab student new to an elementary school reports, 'I just don't want to go to gym class.' Which factor would be of primary concern for a school nurse?
- A. The student's family's cultural beliefs regarding females interacting with males in public
- B. Complaints from others of 'bullying' that occurs in gym class
- C. The student's problems adjusting to the new school environment
- D. A teacher's concern that the gym class is overcrowded
Correct Answer: B
Rationale: The correct answer is B because the primary concern for the school nurse would be addressing any potential bullying the Arab student is experiencing in gym class. This is important for the student's well-being and mental health. Choice A is not the primary concern as it does not directly address the student's reluctance to attend gym class. Choice C focuses on general adjustment issues, while choice D pertains to a logistical issue rather than the student's emotional or social well-being. Addressing bullying is crucial to creating a safe and inclusive environment for the student.
Confidentiality should be discussed with all adolescents and parents before the consult. Confidentiality may be breached in all situations below EXCEPT:
- A. Disclosure of sexual abuse
- B. Disclosure of drug abuse
- C. Disclosure of suicidality
- D. Disclosure of dropping grades
Correct Answer: D
Rationale: Confidentiality can be breached for safety concerns (abuse, drug use, suicidality), but dropping grades is not a direct threat to safety or health, so it does not warrant breaching confidentiality.
The patient tells his primary nurse 'I get into trouble because I have hair-trigger responses. I shoot from the hip. Lots of times that gets me into a mess.' Which response would be most therapeutic?
- A. Let's look at ways to help you slow it down and think before acting.'
- B. It might help to explore how you came to be that way"“any ideas?'
- C. I'll bet you have some interesting stories to share about overreacting.'
- D. It's good that you're showing readiness and motivation to change.'
Correct Answer: A
Rationale: The correct answer is A because it demonstrates empathy and offers a therapeutic approach to help the patient manage their hair-trigger responses. By suggesting ways to slow down and think before acting, the nurse is providing practical strategies for the patient to work on self-regulation and impulse control. This response shows active listening and a commitment to supporting the patient in developing coping mechanisms.
Option B is incorrect as it focuses on exploring the root cause rather than offering immediate support. Option C is incorrect as it may encourage dwelling on past mistakes rather than focusing on problem-solving. Option D is incorrect as it praises the patient without addressing the need for behavior change.