Nokea
Marty is a 15-year-old boy whose parents have brought him to a mental health clinic for evaluation. They are concerned because his grades have fallen and he has become angry and sometimes even violent. He spends long periods of time alone and does not want to see his friends. The parents report that he has never been a bad boy nor had problems in school. They are worried about the changes in his behavior. Which of the following is the most likely cause?
- A. Depression
- B. Running around with a tough crowd
- C. Normal adolescent phase
- D. Attention deficit hyperactivity disorder
Correct Answer: A
Rationale: In addition to classic symptoms of depression, adolescents often display irritability and problems in school performance. This is not normal teen behavior. Because Marty has been functioning well in school up until now, it is unlikely that ADHD would be exhibited at this point.
You may also like to solve these questions
A patient with acute mania dances atop a pool table, waves a cue in one hand, and says, "I'll throw the pool balls if anyone comes near me." The nurse's first intervention is to:
- A. Tell the patient
- B. ""We are taking you to seclusion.""
- C. Remove the patient from the pool table.
- D. Clear the room of all other patients.
Correct Answer: B
Rationale: The correct answer is B because taking the patient to seclusion ensures safety for both the patient and others. This intervention controls the immediate risk of harm from the patient's unpredictable behavior. Telling the patient (choice A) may escalate the situation. Removing the patient from the pool table (choice C) may not address the underlying threat. Clearing the room of all other patients (choice D) is not the priority; ensuring immediate safety is paramount in this scenario.
A patient with borderline personality disorder has been hospitalized several times after self-injurious behavior and suicide attempts. The patient has entered dialectical behavior therapy on an outpatient basis. During therapy, the advanced practice nurse has been counseling her regarding self-harm behavior management. Today the patient called the nurse and reported 'feeling empty and anxious' and wants to cut herself. Which response would best help in this situation?
- A. Arrange for an emergency admission to a crisis unit.
- B. Arrange for an emergency admission to an inpatient unit.
- C. Assist the patient to identify and choose a coping strategy.
- D. Advise the patient to take an anxiolytic, then go to sleep.
Correct Answer: C
Rationale: The correct response is C: Assist the patient to identify and choose a coping strategy. This choice is the best because it involves helping the patient develop healthy coping mechanisms to manage her distress. This empowers the patient to take control of her emotions and actions in a positive way. Emergency admissions (choices A and B) may not address the underlying issues and could potentially reinforce maladaptive behaviors. Advising medication (choice D) without addressing the emotional distress directly may not provide long-term solutions. In summary, choice C focuses on empowering the patient and addressing the root of the problem, making it the most appropriate response in this scenario.
A new nurse asks the experienced nurse who is caring for a battered woman client, 'Why did you ask about culture when it was obvious you needed to focus on the battering?' The experienced nurse should respond:
- A. It's just a habit I got into a while ago.'
- B. It helps me focus on whether to do a complete physical assessment.'
- C. Culture is a determinant of how women interpret and respond to violence.'
- D. If I know more about her I can refer her to a shelter that caters to her ethnic group.'
Correct Answer: C
Rationale: Rationale:
- Choice C is correct because culture influences how individuals perceive and respond to violence, impacting their help-seeking behaviors and coping mechanisms.
- Understanding the client's cultural background is crucial for providing appropriate care and support.
- Choices A, B, and D are incorrect as they do not address the importance of considering culture in understanding and addressing domestic violence in this context.
When a victim of sexual assault is discharged from the emergency department, the nurse should:
- A. Notify the patient's family of the event to ensure support for the patient.
- B. Offer to stay with the patient until stability is regained.
- C. Advise the patient to try not to think about the assault.
- D. Provide referral information verbally and in writing.
Correct Answer: D
Rationale: The correct answer is D because providing referral information verbally and in writing ensures that the victim has access to appropriate resources for follow-up care and support. This step is crucial in helping the victim navigate the emotional and physical aftermath of the assault.
A: Notifying the patient's family without the patient's consent could violate the patient's privacy and autonomy.
B: While offering to stay with the patient shows support, it may not always be feasible and may not address the victim's long-term needs.
C: Advising the patient to try not to think about the assault is dismissive of their trauma and does not provide constructive support.
A nurse is caring for a patient with bulimia nervosa. What should the nurse do to promote a healthy eating pattern?
- A. Provide a strict, rigid eating schedule without flexibility.
- B. Allow the patient to choose meals without any guidelines.
- C. Encourage regular meals and snacks with a focus on nutrition.
- D. Promote food restriction to avoid feelings of guilt after eating.
Correct Answer: C
Rationale: The correct answer is C because encouraging regular meals and snacks with a focus on nutrition helps stabilize blood sugar levels, reduce binge eating episodes, and promote overall health. This approach also supports the patient in developing a balanced relationship with food.
A: Providing a strict, rigid eating schedule may increase anxiety and reinforce unhealthy behaviors.
B: Allowing the patient to choose meals without guidelines may lead to erratic eating patterns and poor nutrition.
D: Promoting food restriction can exacerbate feelings of guilt and perpetuate the cycle of binge eating.