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A patient is in a smoking cessation program that encourages self-control therapy interventions. Which intervention would the nurse suggest?
- A. Limiting smoking to certain times of the day
- B. Keeping a behavioral diary that tracks when the patient smokes
- C. Identifying factors that encouraged the patient to start smoking
- D. Making plans to spend money saved when smoking stops
Correct Answer: B
Rationale: Self-control therapy emphasizes self-monitoring to identify triggers and patterns, enabling the patient to implement strategies for behavioral change.
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A 34-year-old male with catatonic schizophrenia has been mute and motionless for several days. Which nursing intervention would be an initial priority?
- A. Orienting the patient to the unit.
- B. Reinforcing reality with the patient.
- C. Establishing a nonthreatening relationship.
- D. Administer prescribed medications or intervention
Correct Answer: C
Rationale: Building trust and rapport is essential when working with patients in a catatonic or withdrawn state.
A young woman had just learned of the accidental death of her husband. She begins to cry and states, “It’s not fair! How could he do this to me?” This remark is assessed as:
- A. An explosive episode
- B. An expression of anger
- C. Fear of making decisions alone
- D. A sign of despair.
Correct Answer: B
Rationale: The woman's statement, "It's not fair! How could he do this to me?" expresses a sense of anger and injustice over her husband's accidental death. She is questioning why this has happened to her, which suggests feelings of anger and frustration. This expression is not necessarily a plea for help or a manifestation of fear of making decisions alone, but it is a clear display of anger and a sense of unfairness in the situation.
Which complaint is representative of anxiety in a 6-year-old child?
- A. I worry that my dad will get hurt at work.
- B. I get a stomach ache when it's my weekend at my dad's house.
- C. I can't sleep when I stay at Grandma's because I worry about my mom.
- D. I'm not going to sports camp because I don't like being away from my friends.
Correct Answer: B
Rationale: Children often express anxiety through physical complaints like stomachaches, especially in situations that cause distress or discomfort, such as visiting a noncustodial parent.
Which nursing diagnosis is appropriate for a patient who insists on being called "Your Highness" and demonstrates loosely associated thoughts?
- A. Risk for violence
- B. Defensive coping
- C. Impaired memory
- D. Disturbed thought processes
Correct Answer: D
Rationale: nsisting on being called "Your Highness" and demonstrating loose associations suggests a disturbance in thought processing typical of schizophrenia.
Which older adult patient’s medical conditions support the hypothesis upon which the immunologic theory of aging is based?
- A. Has, at age 64, been diagnosed with type 2 diabete
- B. Has been treated for multiple sclerosis since age 30.
- C. Is managing a 36-year history of chronic Graves’ disease.
- D. Has begun to experience symptoms of rheumatoid arthritis.
Correct Answer: B, C
Rationale: he immunologic theory of aging suggests that aging is associated with increased autoimmunity. Conditions like multiple sclerosis, rheumatoid arthritis, and Graves’ disease reflect immune dysfunction.