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Claudette, the nurse, is conducting group therapy with a group of clients. Which of the following statements made by a client is an example of aggressive communication
- A. I feel angry when you leave me.
- B. I wish you would not make me angry.
- C. It makes me angry when you interrupt me.
- D. You'd better listen to me.
Correct Answer: D
Rationale: The correct answer is D because it is an example of aggressive communication. The statement "You'd better listen to me" is forceful, directive, and implies a threat if the listener does not comply. This type of communication lacks respect for the other person's feelings and boundaries. In contrast, choices A, B, and C express personal feelings and thoughts without being demanding or confrontational. Choice A uses "I feel" to express emotions, choice B expresses a wish without placing blame, and choice C explains a reaction to a specific behavior without being forceful. Therefore, D stands out as the only example of aggressive communication in the given options.
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A nurse is assessing a client diagnosed with schizophrenia who has been treated with fluphenazine (Prolixin) for several years. Which of the following findings should the nurse document as manifestations of tardive dyskinesia (TD)?
- A. Sudden onset of high fever
- B. Twisting tongue movements
- C. Constant tapping of feet when sitting
- D. Shuffling gait
Correct Answer: B
Rationale: Twisting tongue movements are a classic sign of tardive dyskinesia from long-term antipsychotic use.
A nurse is caring for a child who has autism spectrum disorder. Which of the following findings should the nurse expect? (Select all that apply.)
- A. Ritualistic behavior
- B. Short attention span
- C. Spinning a toy repetitively
- D. Consistent limit testing
- E. Delayed language development
Correct Answer: A,B,C,E
Rationale: The correct findings for a child with autism spectrum disorder are A, B, C, and E. A: Ritualistic behavior is common in children with ASD due to their need for predictability and routine. B: Short attention span is often seen in children with ASD, affecting their ability to focus on tasks. C: Spinning a toy repetitively is a stereotypical behavior associated with ASD, serving as a self-soothing mechanism. E: Delayed language development is a hallmark feature of ASD, impacting communication skills. These findings align with the core characteristics of ASD. Choices D and beyond are incorrect as they do not typically align with common manifestations of ASD in children.
A nurse is caring for a group of older adult clients. Which of the following manifestations indicates one of the clients is experiencing delirium?
- A. A client attempts to climb out of bed and repeatedly states she must get home.
- B. A client refuses to get out of bed and has no motivation to attend to daily hygiene.
- C. A client wants to know the current time while there is a clock on the wall.
- D. A client requests extra blankets when the thermostat in the room indicates 25.6°C (78°F).
Correct Answer: A
Rationale: The correct answer is A. Delirium is characterized by sudden onset confusion and disorientation. In this case, the client attempting to climb out of bed and repeatedly stating she must get home indicates altered mental status and confusion, which are common in delirium. The other choices do not align with typical manifestations of delirium. Choice B suggests lack of motivation, choice C is a normal behavior to check the time, and choice D is a reasonable request based on personal preference rather than a sign of delirium.
A nurse is assessing a child. The nurse should identify which of the following findings puts the child at risk for the development of conduct disorder?
- A. The child was not promoted to the next grade.
- B. The child moved to three new homes over a two-year period.
- C. The child's best friend was absent from the child's birthday party.
- D. The child has been raised by a parent who has recurrent major depressive disorder.
Correct Answer: D
Rationale: The correct answer is D, as a child raised by a parent with major depressive disorder is at risk for conduct disorder due to the potential lack of emotional support, inconsistent parenting, and exposure to negative behaviors. This can lead to the child developing conduct issues. Choices A, B, and C do not directly correlate with the development of conduct disorder as they do not involve a significant risk factor like living with a parent with major depressive disorder.
Charles, the nurse, is working in an emergency department and is assessing a preschool-age child who reports abdominal pain. Which of the following findings should alert the nurse to possible abuse (select all that apply)
- A. Areas of ecchymosis on the torso.
- B. Mismatched clothing
- C. Abrasions on knees
- D. Abdominal rebound tenderness
- E. Round burn marks on forearms
Correct Answer: A,E
Rationale: The correct answers are A and E. Ecchymosis on the torso may indicate physical abuse, and burn marks on the forearms suggest possible abuse as well. Mismatched clothing (B) is not a direct indicator of abuse but may suggest neglect. Abrasions on knees (C) are common in preschool-age children and do not specifically point to abuse. Abdominal rebound tenderness (D) is a medical finding that may indicate a health issue but does not directly correlate with abuse. Overall, A and E are the most concerning findings that should alert the nurse to possible abuse.