Nokea
In autistic spectrum disorder when as individual exhibits immediate imitation of words or sounds they have just heard, this is known as:
- A. Echoastic disorder
- B. Phonological inhibition
- C. Echolalia
- D. Grapheme dysfunction
Correct Answer: C
Rationale: Echolalia: The immediate imitation of words or sounds heard, a common feature in autistic spectrum disorder.
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A child, aged 11 years, stays home from school to care for his siblings while his mother works, because the family cannot afford a babysitter. The home is cluttered and dirty when the community mental health nurse visits to investigate the child's school absences. When the parents arrive home from work, the child's father behaves angrily. He orders his wife and son about. He finds fault with the son, asking him twice, 'Why are you such a stupid kid?' The wife tells the nurse she has difficulty disciplining the children and gets frustrated easily. The nurse desires to build some trust and continue to gather assessment data. The remark or question that would interfere with the nurse's goals is:
- A. Tell me what happens when the children misbehave.'
- B. When your baby cries, how do you get him to stop?'
- C. Caring for three young children must be difficult.'
- D. Do you or your husband ever beat the children?'
Correct Answer: D
Rationale: The correct answer is D. Asking about physical abuse can be perceived as accusatory, defensive, or judgmental, hindering trust-building and data collection. It may lead to denial or termination of communication. Choices A and B are relevant to understanding parenting skills, while C shows empathy. These questions align with the nurse's goal of assessing the family's dynamics without inciting defensiveness or shutting down communication.
A client with antisocial personality disorder yells, 'Shut up about that, or I'll punch you in the nose!' and shakes his fist at another client in a group meeting after the client speaks negatively of illicit drug use. The nurse quickly determines that the client is at risk to act violently against others as evidenced by his aggressive behavior, verbal threats, and a history of impulsivity. Which is the best approach for the nurse to use?
- A. Seclude the client to protect the other clients and staff.
- B. Put the client in restraints to protect the milieu.
- C. Explore alternate ways to handle frustrating topics in the group.
- D. Tell the client to leave the group until he can behave appropriately.
Correct Answer: C
Rationale: The correct answer is C: Explore alternate ways to handle frustrating topics in the group. This approach is best because it focuses on addressing the underlying issue causing the client's aggression rather than just isolating or restraining the client. By exploring alternate ways to handle frustrating topics, the nurse can help the client develop healthier coping mechanisms and communication skills. This approach promotes therapeutic engagement and supports the client's growth and development.
Secluding the client (choice A) may escalate the situation and reinforce the client's aggressive behavior. Putting the client in restraints (choice B) is a restrictive measure that should only be used as a last resort for imminent danger. Telling the client to leave the group (choice D) may not address the root cause of the aggression and could lead to avoidance of addressing the client's issues.
Which is NOT a contributing factor to postpartum blues?
- A. Hormone shifts
- B. Lack of sleep
- C. Stress
- D. History of depression
Correct Answer: D
Rationale: History of depression (D) is a contributor to postpartum depression, not postpartum blues. Hormone shifts (A), lack of sleep (B), and stress (C) are common triggers for the transient sadness of postpartum blues.
A short-term goal for a patient with anorexia nervosa is 'Patient will select and eat a balanced diet.' The nurse writes which of the following nursing interventions into the care plan that will foster attainment of this goal?
- A. Allow patient to weigh self every time a meal is completely eaten.
- B. Assist the patient to fill out the dietary menus to ensure a balanced diet.
- C. Encourage the patient to engage in only appropriate compensatory exercise.
- D. Implement contracted consequences 50% of the time if a meal is not completed.
Correct Answer: B
Rationale: The correct answer is B: Assist the patient to fill out the dietary menus to ensure a balanced diet. This intervention is appropriate because it directly supports the goal of the patient selecting and eating a balanced diet. By assisting the patient in filling out dietary menus, the nurse can help the patient make informed choices about their food intake, ensuring they are consuming a variety of nutrients necessary for a balanced diet. This intervention promotes patient autonomy and education, empowering the patient to make healthier choices.
Choice A is incorrect because allowing the patient to weigh themselves every time a meal is eaten does not directly address the goal of selecting and eating a balanced diet.
Choice C is incorrect because encouraging compensatory exercise may lead to unhealthy behaviors and does not focus on achieving a balanced diet.
Choice D is incorrect because implementing contracted consequences for incomplete meals may create a negative environment and does not promote a positive approach to achieving a balanced diet.
An 85-year-old has difficulty walking after a knee replacement. The patient tells the nurse, 'Its awful to be old. Every day is a struggle. No one cares about old people.' Select the nurses best response.
- A. Everyone here cares about old people. Thats why we work here.'
- B. It sounds like youre having a difficult time. Tell me about it.'
- C. Lets not focus on the negative. Tell me something good.'
- D. You are still able to get around, and your mind is alert.'
Correct Answer: B
Rationale: The nurse uses empathetic understanding to permit the patient to express frustration and clarify her struggle for the nurse. The distracters block communication.