Nokea
On the basis of the nurse's knowledge of autistic behavior, which nursing diagnosis is most likely to be a priority in the team conference?
- A. Ineffective health maintenance
- B. Chronic low self-esteem
- C. Risk for activity intolerance
- D. Risk for self-directed violence
Correct Answer: D
Rationale: Self-directed violence is a priority due to potential self-injurious behaviors.
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If the teenage mother expresses feeling inexperienced and inadequate in caring for the baby, which referral is best?
- A. Project Head Start
- B. Planned Parenthood
- C. Parent-Teacher Association
- D. Parenting classes
Correct Answer: D
Rationale: Parenting classes provide education and support to build confidence and skills.
The nurse is most correct to support the parents as they move through the grieving process. Place the following stages of the grieving process in the chronologic order in which they will most likely occur.
- A. Depression
- B. Anger
- C. Denial
- D. Bargaining
- E. Acceptance
Correct Answer: C,B,D,A,E
Rationale: The Kubler-Ross model typically follows the order: Denial, Anger, Bargaining, Depression, Acceptance.
When crisis intervention is provided, which nursing action takes priority?
- A. Explaining the benefits of professional counseling
- B. Encouraging the survivors to talk about the event
- C. Reassuring the survivors that they will adapt
- D. Advising consulting a physician for drug therapy
Correct Answer: B
Rationale: Talking about the event helps process trauma and is a priority in crisis intervention.
Which nursing action is most appropriate at this time?
- A. Postpone weighing the client until later.
- B. Confront the client about the water intake.
- C. Say nothing and weigh the client as usual.
- D. Subtract 2 lb (0.9 kg) from the client's weight.
Correct Answer: A
Rationale: Postponing weighing ensures accuracy and addresses manipulative behavior.
If this child is typical of others the same age with a serious illness, which concept is the most commonly held belief about being ill?
- A. Illness is not life-threatening; recovery is assured.
- B. Significant others can prevent serious consequences.
- C. Illness is a punishment for some wrong-doing.
- D. Failure to comply with treatment results in parental rejection.
Correct Answer: C
Rationale: School-age children often view illness as punishment due to magical thinking.