Nokea
Sensory experiences that occur in the absence of a stimulus are called
- A. illusions
- B. hallucinations
- C. delusions
- D. affect episodes
Correct Answer: B
Rationale: Hallucinations are perceptions without stimuli, distinct from illusions (misinterpretations).
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Marie is 16 years old. She has been referred to the clinic by the nurse at her school because she started a fight with a younger girl and hurt her badly. The school nurse reports that Marie has been troublesome beforeskipping school, bullying, and smoking on school grounds on several occasions. Of the following, which diagnosis is most likely?
- A. Bipolar depression
- B. Paranoid schizophrenia
- C. Conduct disorder
- D. Dysthymic disorder
Correct Answer: C
Rationale: Conduct disorder is characterized by a pattern of aggressive behavior and violating the rights of others, including defiance and rule breaking. The other responses are psychiatric disorders that would not be the most likely diagnosis given Maries behavior.
A client in the cardiac clinic tells the nurse that he is concerned about his mother, age 75, who lives alone and seems more forgetful. Which statement would be most indicative that the mother may have Alzheimer's disease?
- A. Mom continues to participate in senior center activities each week.'
- B. Mom insists on cooking and cleaning for herself.'
- C. Mom forgot to pay her utility bills last month.'
- D. Mom refuses to stop driving even though her reaction time is very slow.'
Correct Answer: C
Rationale: The correct answer is C because forgetting to pay bills is a common early symptom of Alzheimer's disease due to cognitive decline affecting memory and executive functions. This behavior indicates difficulty with organizing and managing tasks, a hallmark of Alzheimer's. Choices A and B suggest independence and engagement, which are not necessarily indicative of Alzheimer's. Choice D hints at potential safety concerns but does not directly point to cognitive decline related to Alzheimer's.
A client, age 34, has been physically abused by her husband five times during the past 2 years. During her last discussion with the nurse, the client stated, 'I probably should not keep going back to him.' The nurse is aware that the final decision to leave a batterer:
- A. Is complex and may take time.
- B. Should be made immediately.
- C. Is the responsibility of the nurse.
- D. None of the above.
Correct Answer: A
Rationale: The correct answer is A: Is complex and may take time. The nurse understands that leaving an abusive relationship is a complex process that may take time. The client's statement of awareness indicates progress, but making the final decision to leave a batterer involves various factors such as safety planning, emotional readiness, and support systems. Choice B is incorrect as immediate decision-making can be dangerous without proper planning. Choice C is incorrect as the nurse's role is to support and empower the client but not make decisions for them. Choice D is incorrect as leaving an abuser is a personal decision that requires careful consideration.
A student transfers from a hometown college to a university 200 miles away after breaking up with her boyfriend of 2 years. She was slow to make friends at the university. The history shows a close relationship with her mother and sister. She began eating large quantities when she felt sad, and then she induced vomiting. When the student's schoolwork declined, she sought help. During the initial interview, what priority issue should the nurse address?
- A. Losses.
- B. Sleep patterns.
- C. School activities.
- D. None of the above.
Correct Answer: A
Rationale: The correct answer is A: Losses. The priority issue the nurse should address is the student's losses, such as the breakup with her boyfriend and the difficulty in making friends at the new university. This is important because these losses may be contributing to her emotional distress and maladaptive coping mechanisms like binge-eating and induced vomiting. The nurse needs to explore these losses to understand the root cause of the student's behavior and provide appropriate support.
Choice B: Sleep patterns, and Choice C: School activities are not the priority issues in this scenario. While sleep patterns and school activities are important aspects of the student's life, the primary concern here is addressing the emotional impact of the losses she has experienced.
Choice D: None of the above is incorrect because losses are indeed the priority issue that needs to be addressed in this situation. Ignoring the emotional impact of the student's losses could hinder the effectiveness of any interventions or support provided.
Which nursing diagnosis would be appropriate for a patient with Alzheimer disease?
- A. Disorientation related to hyperthermia
- B. Anxiety (moderate) related to dementia
- C. Disturbed sensory perception (visual) related to alcohol abuse
- D. Disturbed thought processes related to irreversible brain disorder
Correct Answer: D
Rationale: The correct answer is D: Disturbed thought processes related to irreversible brain disorder. This nursing diagnosis is appropriate for a patient with Alzheimer's disease because Alzheimer's is characterized by cognitive decline and disturbances in thought processes due to irreversible brain changes. Disorientation related to hyperthermia (A) is not directly associated with Alzheimer's. Anxiety related to dementia (B) is a symptom of Alzheimer's, not a nursing diagnosis. Disturbed sensory perception related to alcohol abuse (C) is not relevant to a patient with Alzheimer's disease. It is crucial to focus on the specific symptoms and characteristics of Alzheimer's disease when selecting the appropriate nursing diagnosis.