Nokea
A patient with mania has not eaten or slept for 3 days. Which nursing diagnosis has priority?
- A. Risk for injury
- B. Ineffective coping
- C. Ineffective management of therapeutic regime
- D. Imbalanced nutrition
Correct Answer: D
Rationale: The correct answer is D: Imbalanced nutrition. Priority is given to physiological needs. The patient not eating for 3 days can lead to serious health complications. This nursing diagnosis addresses the immediate risk to the patient's physical well-being. Choices A, B, and C are important but addressing the patient's nutritional needs is the priority to prevent further deterioration in their condition.
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Which of the following should the nurse use as a basis for explaining the etiology of Alzheimer's disease to the family of a client with this disease?
- A. It is a secondary dementia indicated by loss of recent memory and disorientation to time and place.
- B. It is a primary dementia that is incurable, irreversible, and fatal. It is caused by the presence of a beta-amyloid protein in the neurons resulting in senile plaques.
- C. It is a secondary dementia that is treatable with analysis of the diet and removal of toxic substances from the diet and environment.
- D. It is a primary dementia characterized by stepwise decreases in cognitive abilities. It is irreversible but treatable with antihypertensive medications.
Correct Answer: B
Rationale: The correct answer is B because Alzheimer's disease is a primary dementia that is characterized by the presence of beta-amyloid protein in neurons leading to the formation of senile plaques. This explanation is accurate as it describes the key pathological process underlying Alzheimer's disease.
Choice A is incorrect because Alzheimer's disease is a primary dementia, not a secondary dementia. Choice C is incorrect because the etiology of Alzheimer's disease is not related to diet or toxic substances, so it is not treatable in that way. Choice D is incorrect because while Alzheimer's disease is irreversible, it is not treatable with antihypertensive medications as these medications are not effective in managing the disease process of Alzheimer's.
Which stage of Piaget's theory marks the onset of logical thinking?
- A. Sensorimotor
- B. Preoperational
- C. Concrete Operational
- D. Formal Operational
Correct Answer: C
Rationale: The Concrete Operational stage (C), around age 7-11, marks the onset of logical thinking about concrete events, per Piaget's theory. Earlier stages (A, B) lack this, and Formal Operational (D) involves abstract logic later.
A patient tells the nurse that his sexual functioning is normal when his wife wears short, red camisole-style nightgowns. He states, 'Without the red teddies, I am not interested in sex.' The nurse can assess this as consistent with
- A. exhibitionism.
- B. voyeurism.
- C. frotteurism.
- D. fetishism.
Correct Answer: D
Rationale: The correct answer is D: fetishism. Fetishism is a sexual disorder where a person is sexually aroused by an object or body part that is not typically considered sexual. In this scenario, the patient's arousal is dependent on his wife wearing a specific type of clothing (the red camisole-style nightgowns), indicating a fetishistic preference for that particular item. This is different from exhibitionism (A), which involves exposing one's genitals to unsuspecting strangers; voyeurism (B), which involves observing unsuspecting individuals undressing or engaging in sexual activity; and frotteurism (C), which involves touching or rubbing against a non-consenting person for sexual arousal.
CT scans of the brains of some young schizophrenics show than normal
- A. wider ventricles
- B. smaller fissures
- C. smaller ventricles
- D. fewer fissures
Correct Answer: A
Rationale: Enlarged ventricles in schizophrenics suggest brain abnormalities linked to the disorder.
When a patient with a personality disorder uses manipulation as a way of getting needs met, the staff agree to use limit setting as an intervention. How does limit setting work to reduce manipulation?
- A. Limit setting indulges the patient's desire for attention from staff.
- B. It gives the patient a different concern on which to focus his anger.
- C. External controls provide security while internal controls are developing.
- D. When staff limit the patient's behavior, he is no longer anxious about it.
Correct Answer: C
Rationale: Correct Answer: C
Rationale:
1. External controls, like limit setting, provide structure and predictability for the patient.
2. This security allows the patient to gradually develop internal controls to manage their behavior.
3. By relying on external limits, the patient's need for manipulation decreases over time.
4. This approach fosters growth and autonomy in the patient, reducing the reliance on manipulative behaviors.
Summary:
A: Incorrect. Limit setting does not indulge attention-seeking behaviors; it establishes boundaries.
B: Incorrect. Limit setting does not redirect anger; it focuses on promoting internal control.
D: Incorrect. Limit setting does not solely address anxiety; it aims to foster self-regulation.