Nokea
Children should undergo further evaluation when their weight is % above their height.
- A. 10
- B. 15
- C. 20
- D. 25
Correct Answer: C
Rationale: The correct answer is C (20%). This is because a weight that is 20% above a child's height can indicate potential health issues such as obesity. Excess weight can lead to various health problems in children. Choices A, B, and D are incorrect as they represent lower percentages, which may not be as concerning in terms of potential health risks. It is important to consider a higher percentage threshold for further evaluation to ensure early detection and intervention for any weight-related issues.
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A patient remanded by the court after his wife had him jailed for battery told the judge how sorry he was and suggested he needed psychiatric help. His history reveals acting-out behaviors as an adolescent and several adult arrests. The nurse interviews him about his relationship with his wife. Which statement by the patient is most consistent with a diagnosis of antisocial personality disorder?
- A. I've done some stupid things in my life, but I've learned a lesson.'
- B. I'm feeling terrible about the way my behavior has hurt my family.'
- C. I have a quick temper, but I can usually keep it under control.'
- D. I hit her because she nags at me. She deserves it when I beat her up.'
Correct Answer: D
Rationale: The correct answer is D. This statement reflects a lack of remorse, empathy, and justification for violent behavior, which are key characteristics of antisocial personality disorder. The patient blames his wife for his violent actions and shows a sense of entitlement.
A: This statement shows acknowledgment of mistakes and a willingness to learn from them, which is not consistent with antisocial personality disorder.
B: Expressing feeling terrible about hurting family members demonstrates some level of empathy and remorse, which is not typical of individuals with antisocial personality disorder.
C: Acknowledging a quick temper but being able to control it does not align with the impulsivity and lack of control often seen in individuals with antisocial personality disorder.
A client seen by the rape crisis nurse 1 month after the incident states, 'I'm confused and just not myself. I have mood swings during the day, and I have nightmares at night. Sometimes I think I'm going crazy.' Other times, she is just plain afraid to be alone. The nurse should assess the client for:
- A. Trauma syndrome.
- B. Post-traumatic stress disorder.
- C. Acute stress disorder.
- D. None of the above.
Correct Answer: A
Rationale: The correct answer is A: Trauma syndrome. This choice is correct because the client's symptoms of confusion, mood swings, nightmares, feeling like they are going crazy, and fear of being alone align with the criteria for trauma syndrome. This syndrome encompasses a range of symptoms that occur after experiencing a traumatic event, such as rape.
Choice B: Post-traumatic stress disorder (PTSD) is not the best option in this case because the client's symptoms are more indicative of acute distress and confusion rather than the criteria for a formal diagnosis of PTSD, which typically requires the persistence of symptoms over time.
Choice C: Acute stress disorder is also not the most appropriate choice because while some symptoms may align, the duration and specific criteria for this disorder may not fully match the client's presentation.
Choice D: None of the above is incorrect as trauma syndrome best fits the client's symptoms based on the information provided.
An individual brought by ambulance to the emergency room is accompanied by a roommate. The patient fights against the restraints and shouts incoherently. The roommate reports that the patient was weak and confused on awakening this morning and about 3 hours ago began "rambling and talking crazy."Â A nurse notes that the patient's skin is flushed and dry. The priority nursing action is to:
- A. take the patient's vital signs.
- B. start intravenous fluids.
- C. administer a sedative.
- D. perform a mental status examination.
Correct Answer: A
Rationale: The correct answer is A: take the patient's vital signs. This is the priority action because the patient is exhibiting signs of potential medical emergency, such as altered mental status, flushed and dry skin, and confusion. Vital signs can provide crucial information about the patient's condition and help determine the urgency of the situation. Starting intravenous fluids (B) may be necessary but should be based on the assessment of vital signs first. Administering a sedative (C) is not appropriate without knowing the underlying cause of the symptoms. Performing a mental status examination (D) is important but not the priority in this situation where the patient's physical condition needs immediate attention.
Several children a day are seen in the emergency department for treatment of illnesses and injuries. The situation that would create a high index of suspicion of child abuse is a child who:
- A. Has repeated middle ear infections.
- B. Complains of abdominal cramps and upset stomach.
- C. Has perineal bruises and urinary tract infections.
- D. Displays reduced functioning at school.
Correct Answer: C
Rationale: The correct answer is C because perineal bruises and urinary tract infections are physical signs that are highly suspicious for child abuse, particularly sexual abuse. Perineal bruises are not commonly seen in children due to accidental injuries, and urinary tract infections in young children are rare and may indicate sexual abuse. Repeated middle ear infections (choice A) and complaints of abdominal cramps and upset stomach (choice B) are common childhood illnesses that do not necessarily indicate child abuse. Displaying reduced functioning at school (choice D) may suggest various issues such as learning disabilities or emotional distress, but is not specific to child abuse.
In some countries, it is normal to defecate or urinate in public. This makes it clear that judgments of the normality of behavior are
- A. culturally relative
- B. statistical
- C. a matter of subjective discomfort
- D. related to conformity
Correct Answer: A
Rationale: Normality varies by culture, as behaviors acceptable in one society may be abnormal in another.