Nokea
A preschool-aged girl tells the school nurse that her hair hurts. The nurse finds that the child's hair has been arranged to cover several small bald spots. Which finding indicates to the nurse that the hair loss is not disease related?
- A. Episodic intervals of pruritus
- B. Erythema of the localized lesions
- C. Ecchymotic blood accumulations
- D. Evidence of patches of lost hair
Correct Answer: C
Rationale: Ecchymotic blood accumulations suggest trauma, such as hair-pulling (e.g., trichotillomania), indicating a non-disease-related cause. Pruritus and erythema suggest dermatological issues. Patches of hair loss alone do not specify the cause.
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The nurse documents that a client with schizophrenia is delusional. Which statement by the client confirms this assessment?
- A. The snakes on the wall are going to eat me
- B. The nurse at night is trying to poison me with pills
- C. The voices are telling me to kill the next person I see
- D. The fire is burning my skin away right now
- E. None
- F. None
Correct Answer: B
Rationale: The nurse at night is trying to poison me with pills' confirms a delusion, specifically a paranoid delusion, as it reflects a fixed, false belief not based in reality. The other options describe hallucinations: visual ('snakes'), auditory ('voices'), and tactile ('fire'). Delusions involve false beliefs, while hallucinations involve false sensory perceptions.
The nurse continues caring for the client:
The client is a 26-year-old female who was in a car accident 6 months s ago that killed her mother, husband, and 2-year-old son. She and her father were the only survivors of the crash. She is seeking care for depression.
Click to indicate whether findings at the next follow-up appointment indicate that the treatment was effective or ineffective. Each row must have one response selected.
- A. The client talks to her father and her best friend when she starts to feel sad: Effective
- B. The client states she feels numb when thinking about the crash: Ineffective
- C. The client states that she avoids driving altogether and takes the bus: Effective
- D. The client reports sleeping 6 to 7 hours per night: Effective
- E. The client states she feels less jumpy and more relaxed: Effective
Correct Answer: A,B,C,D,E
Rationale: A: Seeking support is a positive coping mechanism (Effective). B: Numbness suggests unresolved trauma (Ineffective). C: Avoiding driving reduces distress (Effective). D: Adequate sleep indicates improvement (Effective). E: Reduced anxiety shows treatment efficacy (Effective).
A young female client is admitted to the emergency room because she was raped that evening by her date. Which computer documentation should the nurse enter in the electronic medical record as the client's chief complaint?
- A. Client claims that she was forced to participate in sexual intercourse
- B. Client reported that she had sexual relations against her will
- C. Client has been sexually assaulted
- D. Client states, 'My date raped me tonight'
Correct Answer: D
Rationale: Client states, 'My date raped me tonight' is the most accurate and objective, using the client's own words to document the chief complaint without implying doubt ('claims') or minimizing the trauma. 'Sexual assault' is accurate but less specific.
A client who has agoraphobia is beginning desensitization with the therapist, and the nurse is reinforcing the process. Which intervention has the highest priority for this client's plan of care?
- A. Establish trust by providing a calm, safe environment
- B. Encourage deep breathing when anxiety escalates in a crowd
- C. Progressively expose the client to larger crowds
- D. Encourage substitution of positive thoughts for negative ones
Correct Answer: A
Rationale: Establishing trust through a calm, safe environment is foundational for effective desensitization in agoraphobia, supporting the client's sense of security. Deep breathing and positive thoughts are secondary. Progressive exposure comes after trust is established.
Mark which behaviors might be related to alcohol intoxication, acute phase of rape-trauma syndrome, or both. Tick only 1 box.
- A. Numbness: Rape-trauma syndrome
- B. Poor decision making: Alcohol intoxication
- C. Crying: Both
- D. Disbelief: Rape-trauma syndrome
- E. Irritability: Alcohol intoxication
- F. Difficulty concentrating: Both
Correct Answer: C
Rationale: Crying occurs in both alcohol intoxication (due to disinhibition) and rape-trauma syndrome (due to emotional distress). Numbness and disbelief are specific to rape-trauma syndrome. Poor decision making, irritability, and difficulty concentrating are typical of alcohol intoxication, though the latter can also occur in rape-trauma syndrome.