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In DSM-IV-TR intellectual disabilities are divided into a number of degrees of severity, depending primarily on the range of IQ score provided by the sufferer. One of these is Profound Mental Retardation, represented by an IQ score below:
- A. 20-25
- B. 25-30
- C. 15-20
- D. 15-Oct
Correct Answer: A
Rationale: Profound Mental Retardation: Defined by DSM-IV-TR as an IQ score below 20-25.
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Disturbed body image is the nursing diagnosis for a patient with an eating disorder. Which outcome indicator is most applicable to this diagnosis?
- A. Weight, muscle, and fat congruence with height, frame, age, and sex.
- B. Calorie intake within required parameters of treatment plan.
- C. Weight at established normal range for the patient.
- D. None of the above.
Correct Answer: A
Rationale: The correct answer is A because disturbed body image in an eating disorder patient involves a discrepancy between their perceived body image and reality. Monitoring weight, muscle, and fat congruence with height, frame, age, and sex helps assess if the patient's perception aligns with their actual physical state. Choice B focuses solely on calorie intake, which does not directly address body image perception. Choice C only considers weight, neglecting the importance of muscle and fat distribution in body image perception. Choice D is incorrect as option A is the most relevant outcome indicator for disturbed body image in this scenario.
Which assessment finding is most associated with bulimia nervosa?
- A. Prominent parotid glands
- B. Peripheral edema
- C. Thin, brittle hair
- D. Amenorrhea
Correct Answer: A
Rationale: The correct answer is A: Prominent parotid glands. This is associated with bulimia nervosa due to repeated vomiting, which can lead to enlargement of the parotid glands. This is known as parotid gland hypertrophy. The other choices (B: Peripheral edema, C: Thin, brittle hair, D: Amenorrhea) are more commonly associated with anorexia nervosa rather than bulimia nervosa. Edema is a sign of malnutrition in anorexia, while thin, brittle hair and amenorrhea are also common in anorexia due to severe weight loss and hormonal disturbances.
When a patient with anorexia nervosa expresses a fear of weight gain, the nurse should respond by:
- A. Minimizing the patient's concerns to avoid anxiety.
- B. Encouraging weight loss to meet the patient's goals.
- C. Explaining that weight gain is part of the treatment plan.
- D. Agreeing with the patient's view on body image to reduce conflict.
Correct Answer: C
Rationale: The correct response is C: Explaining that weight gain is part of the treatment plan. This answer is correct because in treating anorexia nervosa, it is essential for patients to understand that weight gain is necessary for recovery and overall health improvement. By explaining this, the nurse can help the patient develop a more positive attitude towards weight gain and recognize it as a crucial aspect of the treatment process.
Choices A, B, and D are incorrect:
A: Minimizing the patient's concerns may invalidate their feelings and hinder therapeutic communication.
B: Encouraging weight loss would be counterproductive and reinforce the patient's negative behaviors and beliefs.
D: Simply agreeing with the patient's view on body image without addressing the need for weight gain would not promote positive change or support the patient's recovery.
The emergency department note states, 'This patient displays positive symptoms of schizophrenia as evidenced by psychotic disorders of thinking.' The nurse can expect the patient to evidence:
- A. delusions and hallucinations.
- B. grimacing and mannerisms.
- C. echopraxia and echolalia.
- D. avolition and anhedonia.
Correct Answer: A
Rationale: The correct answer is A: delusions and hallucinations. Positive symptoms of schizophrenia include hallucinations (perceiving things that are not present) and delusions (false beliefs). In this case, the patient displaying psychotic disorders of thinking aligns with positive symptoms. Delusions are fixed false beliefs, while hallucinations involve sensory experiences without external stimuli. Choices B, C, and D involve different symptoms such as motor abnormalities (grimacing and mannerisms), echopraxia and echolalia (mimicking movements and repeating words), and negative symptoms (avolition and anhedonia - lack of motivation and pleasure), which are not specifically related to psychotic disorders of thinking in schizophrenia.
The therapeutic approach in the care of an autistic child include the following EXCEPT:
- A. Engage in diversionary activities when acting out
- B. Provide an atmosphere of acceptance
- C. Provide safety measures
- D. Rearrange the environment to activate the child
Correct Answer: D
Rationale: Rearranging the environment to activate the child may overstimulate an autistic child, who typically benefits from consistency and calm settings.