Nokea
An 11-year-old child stays home from school to care for his siblings while his mother works, is demeaned by his father, and has negative self-perceptions. Which indicator would suggest that nursing interventions are succeeding?
- A. The child attends school regularly.
- B. The child is observed playing calmly.
- C. The father rarely speaks during nurse visits.
- D. The mother corrects negative comments by the child.
Correct Answer: A
Rationale: The correct answer is A because regular school attendance indicates the child's improved well-being and ability to prioritize education over caregiving responsibilities.
B: Playing calmly does not necessarily indicate overall improvement in the child's situation.
C: The father's silence during nurse visits does not directly reflect the child's well-being or progress.
D: The mother correcting negative comments by the child is positive but does not directly address the child's caregiving responsibilities or self-perceptions.
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A depressed patient tells the nurse, "The bad things that happen are always my fault." How should the nurse respond to assist the patient to reframe this overgeneralization?
- A. I really doubt that one person can be blamed for all the bad things that happen.
- B. You are being exceptionally hard on yourself when you imply you are a jinx.
- C. What about the good things that happen; are any of those ever your fault?
- D. Let's look at one bad thing that happened to see if another explanation exists.
Correct Answer: D
Rationale: The correct answer is D because it encourages the patient to challenge the overgeneralization by exploring alternative explanations for a specific event. By examining one bad thing in detail, the patient can see that not everything is their fault, promoting a more balanced perspective.
A is incorrect because it simply doubts the patient's statement without providing a constructive way to reframe it. B is incorrect as it introduces the idea of being a jinx, which may further reinforce the patient's negative self-perception. C is incorrect as it diverts the focus to good things, which does not address the patient's negative beliefs about themselves.
schizophrenia usually involves delusions of persecution and grandeur
- A. Catatonic
- B. Disorganized
- C. Paranoid
- D. Undifferentiated
Correct Answer: C
Rationale: Paranoid schizophrenia is marked by prominent delusions of persecution or grandeur.
An adolescent patient is diagnosed with dementia. The patient's age would cause a nurse to suspect which underlying condition sometimes associated with this diagnosis?
- A. Head trauma
- B. Neurosyphilis
- C. Pick disease
- D. Hypothyroidism
Correct Answer: A
Rationale: The correct answer is A: Head trauma. Adolescents are less likely to develop dementia due to age-related neurodegenerative diseases. Head trauma can lead to cognitive impairment and memory loss, mimicking symptoms of dementia. Neurosyphilis is a sexually transmitted infection affecting the brain, not common in adolescents. Pick disease is a rare neurodegenerative disorder more commonly seen in older adults. Hypothyroidism can cause cognitive symptoms but is not typically associated with dementia in adolescents.
An unusual state called 'waxy flexibility' is sometimes observed in schizophrenia
- A. borderline
- B. disorganized
- C. catatonic
- D. paranoid
Correct Answer: C
Rationale: Waxy flexibility, a motor symptom, is unique to catatonic schizophrenia.
A nursing diagnosis for a patient with bulimia nervosa is Ineffective coping related to feelings of loneliness and isolation, as evidenced by use of overeating and self-induced vomiting to comfort self. Select the best outcome related to this diagnosis. Within 2 weeks, the patient will:
- A. Appropriately express angry feelings.
- B. Verbalize two positive things about self.
- C. Verbalize the importance of eating a balanced diet.
- D. None of the above.
Correct Answer: D
Rationale: Rationale:
1. Patient's diagnosis indicates coping issues, not anger expression or self-esteem.
2. Patient's coping mechanism involves overeating and vomiting, not diet.
3. Outcome should focus on coping skills improvement, not unrelated goals.
4. None of the choices address the root issue of coping with loneliness and isolation.
5. Thus, the correct answer is D, as none of the options directly address the patient's ineffective coping mechanism.