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During a therapy session, a patient is asked to rate the intensity of his current issue from 1 to 10 with 1 being complete absence of the issue and 10 being the most intense. The patient is being asked which type of question?
- A. Relationship
- B. Miracle
- C. Scaling
- D. Exception
Correct Answer: C
Rationale: The correct answer is C: Scaling. Scaling questions involve asking clients to rate the intensity of their issues on a numerical scale, just like in this scenario. This helps therapists understand the perceived severity of the problem and track changes over time. Relationship questions focus on interpersonal dynamics, miracle questions explore ideal outcomes, and exception questions inquire about times when the issue is not present. In this case, the question about rating intensity aligns best with the scaling technique.
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A nurse on an acute med-surgical unit is performing assessments on a group of clients. Which is the highest priority?
- A. The client has surgical hypoparathyroidism and positive Trousseau's sign.
- B. A client who has Clostridium difficile with acute diarrhea
- C. A client who is experiencing acute kidney injury and has urine with a low specific gravity
- D. The client who has oral cancer and reports a sore on his gums
Correct Answer: A
Rationale: The correct answer is A because the client with surgical hypoparathyroidism and positive Trousseau's sign indicates a potential life-threatening condition due to hypocalcemia. Trousseau's sign is a clinical indicator of hypocalcemia, which can lead to serious complications such as seizures and tetany. This client needs immediate intervention to prevent further complications.
Choice B is incorrect because while Clostridium difficile with acute diarrhea requires prompt treatment, it is not as immediately life-threatening as hypocalcemia. Choice C is incorrect as well, as although acute kidney injury is serious, a low specific gravity alone does not necessarily indicate an immediate threat to the client's life. Choice D is also incorrect as oral cancer with a sore on the gums, while concerning, is not an immediate priority compared to the potential life-threatening complications of hypocalcemia.
After describing the various legislative efforts to address the issue of homelessness in the United States, a nursing instructor determines that the teaching was successful when the students identify which of the following as addressing the need for a continuum of care approach?
- A. Bringing Home America Act
- B. Affordable Care Act
- C. American Recovery and Reinvestment Act
- D. McKinney-Vento Homeless Assistance Act
Correct Answer: D
Rationale: The correct answer is D: McKinney-Vento Homeless Assistance Act. This act addresses the need for a continuum of care approach by providing federal funding for homeless assistance programs that offer a range of services to individuals experiencing homelessness. It emphasizes the importance of coordination among various service providers to ensure a seamless transition from emergency shelters to permanent housing.
Choice A: Bringing Home America Act does not specifically focus on homeless assistance programs or the continuum of care approach.
Choice B: Affordable Care Act primarily focuses on healthcare reform and expanding access to healthcare services, not specifically related to addressing homelessness.
Choice C: American Recovery and Reinvestment Act aims to stimulate economic recovery through job creation and infrastructure projects, not directly related to addressing homelessness or providing a continuum of care approach.
As a nurse working in obstetrics, what is one way to mitigate possible causes of intellectual disability?
- A. Explain to the parent the treatment options available.
- B. Explain to the parent environmental risks to avoid during pregnancy.
- C. Explain to the parent that genetics have a role in this disability.
- D. Explain to the parent that learning disabilities often go unnoticed until the child enters school.
Correct Answer: B
Rationale: The correct answer is B because avoiding environmental risks during pregnancy can help mitigate possible causes of intellectual disability. Environmental factors such as exposure to toxins, infections, and poor nutrition can have a significant impact on fetal brain development. By educating parents about these risks, nurses can empower them to make informed choices to protect their baby's cognitive development.
Choice A is incorrect because treatment options are not preventive measures to avoid intellectual disability.
Choice C is incorrect because while genetics can play a role in intellectual disability, it is not something parents can actively mitigate during pregnancy.
Choice D is incorrect because learning disabilities are different from intellectual disabilities, and addressing them at school age is not a preventive measure during pregnancy.
A nursing student is assigned to care for a patient diagnosed with schizophrenia. When talking about this patient in a clinical postconference, the student would use which terminology when referring to the patient?
- A. Committed patient
- B. Schizophrenic
- C. Schizophrenic patient
- D. Person with schizophrenia
Correct Answer: D
Rationale: The correct answer is D: Person with schizophrenia. This terminology aligns with person-first language, which emphasizes the individuality and humanity of the patient over their diagnosis. It is important to use person-first language to promote respect and reduce stigma. Using terms like "committed patient" (A) can be stigmatizing and inaccurate, as not all patients with schizophrenia are committed involuntarily. "Schizophrenic" (B) and "schizophrenic patient" (C) both label the individual by their diagnosis, which can be dehumanizing and reduce their identity to just their condition. In contrast, "person with schizophrenia" (D) acknowledges the personhood of the individual first and foremost.
A patient whose history includes experiences with abusive partners is being treated for major depressive disorder. The patient's care plan includes rape-trauma syndrome among its nursing diagnoses. What goal is directly associated with this diagnosis?
- A. Remains free from self-harm
- B. Wears appropriate clothing
- C. Reports feeling stronger and having a sense of hopefulness
- D. Demonstrates appropriate affect for both positive and negative emotions
Correct Answer: C
Rationale: The correct answer is C: Reports feeling stronger and having a sense of hopefulness. This goal is directly associated with rape-trauma syndrome as it focuses on the patient's emotional healing and empowerment. By reporting feeling stronger and having hope, the patient is demonstrating progress towards recovery from the trauma. Choice A is incorrect because remaining free from self-harm is more related to monitoring safety rather than addressing the emotional impact of the trauma. Choice B is irrelevant as wearing appropriate clothing does not directly address the emotional healing process. Choice D is incorrect as demonstrating appropriate affect does not specifically target the psychological aspect of overcoming trauma.