Nokea
A patient's body is covered by fine, downy hair. The patient weighs 70 pounds and is 5 feet 4 inches tall. Which term should be documented?
- A. Amenorrhea
- B. Alopecia
- C. Lanugo
- D. Stupor
Correct Answer: C
Rationale: The correct term to be documented is C: Lanugo. Lanugo is fine, downy hair that can cover a patient's body, often seen in newborns or individuals with certain medical conditions. In this case, the presence of lanugo indicates a potential underlying issue. Amenorrhea (A) refers to the absence of menstruation, not related to the hair. Alopecia (B) is hair loss, the opposite of lanugo. Stupor (D) is a state of reduced consciousness, not related to the hair condition described. Therefore, choice C is the correct answer as it directly matches the description given in the question.
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How the child's development is influenced by the school and the teacher?
- A. mental
- B. social
- C. emotional
- D. all of these
Correct Answer: D
Rationale: Schools and teachers shape children holistically. Mental development occurs through intellectual stimulation (A), social development via peer interactions (B), and emotional development through resilience and self-awareness (C). 'All of these' (D) reflects their comprehensive influence.
The client has become unable to recognize formerly familiar objects and people in his environment. The client is experiencing:
- A. Affect "“ experienced feelings and emotions
- B. Agnosis "“ inability to recognize familiar objects or people
- C. Apraxia "“ difficulty carrying out purposeful, organized task that is somewhat complex (ex. dressing)
- D. Anhedonia "“ lack of pleasure
Correct Answer: B
Rationale: The correct answer is B: Agnosis - inability to recognize familiar objects or people. This is because the client's inability to recognize formerly familiar objects and people in his environment aligns with the definition of agnosis. Affect (choice A) refers to experienced feelings and emotions, which is not the issue described in the question. Apraxia (choice C) is difficulty carrying out purposeful tasks, not related to recognition of objects or people. Anhedonia (choice D) is a lack of pleasure, which is also not applicable to the client's situation. Therefore, the best fit for the client's experience is agnosis.
The nurse is sitting with a patient diagnosed as having schizophrenia, disorganized type, who starts to laugh uncontrollably, although nothing funny has occurred. The nurse should say:
- A. Please share the joke with me.'
- B. Why are you laughing?'
- C. I don't think I said anything funny.'
- D. You're laughing. Tell me what's happening.'
Correct Answer: D
Rationale: The correct answer is D because it acknowledges the patient's behavior in a non-confrontational manner and invites the patient to share their experience. By saying "You're laughing. Tell me what's happening," the nurse shows empathy and encourages open communication. Choice A may unintentionally minimize the patient's experience. Choice B may come off as accusatory. Choice C doesn't actively engage the patient in conversation. Encouraging the patient to express their feelings can help establish trust and facilitate therapeutic communication.
What is the most appropriate goal for a nurse caring for a patient with anorexia nervosa?
- A. The patient will gain weight rapidly to achieve a normal weight.
- B. The patient will stabilize their weight and maintain adequate nutrition.
- C. The patient will achieve full recovery without needing additional support.
- D. The patient will accept their body image as normal and healthy.
Correct Answer: B
Rationale: The most appropriate goal for a nurse caring for a patient with anorexia nervosa is for the patient to stabilize their weight and maintain adequate nutrition (Choice B). This goal is crucial because rapid weight gain can have negative physical and psychological consequences for the patient. Stabilizing weight helps prevent complications like refeeding syndrome and supports the patient's overall health. It also addresses the immediate nutritional needs of the patient. Choices A, C, and D are incorrect because rapid weight gain can be harmful, full recovery often requires ongoing support, and body image acceptance may not be the most pressing concern for someone with anorexia nervosa.
The nurse is interviewing a client who presents with a dislocated shoulder. She demonstrates signs of anxiety and poor eye contact and turns to her partner for answers, allowing him to answer for her. Bruises on her breast and upper arm are visible. The nurse asks the partner to go to the admitting office to give insurance information. While the partner is out of the room, which question is most important to ask?
- A. Have you been with your partner long?'
- B. Have you ever been physically or emotionally hurt by someone?'
- C. Are you an abused woman?'
- D. Shall I notify the police that you would like to press charges?'
Correct Answer: B
Rationale: The correct answer is B: "Have you ever been physically or emotionally hurt by someone?" This question is important as it directly addresses the potential abuse the client may be experiencing. It allows the nurse to assess for any history of abuse, which could be contributing to the client's anxiety and behavior. It also opens up an opportunity for the client to disclose any abuse they may be facing.
Choice A is incorrect because the length of the relationship with the partner is not as crucial as addressing the potential abuse. Choice C is also incorrect because it is too direct and may not encourage the client to open up about their experiences. Choice D is incorrect as it assumes the client wants to press charges without first assessing the situation and the client's wishes.