Nokea
The following descriptions of a client's experience and behavior can be assessed as an illusion.
- A. The client tries to hit the clinical officer when vital signs must be taken
- B. The client says, 'I keep hearing a voice telling me to run away'
- C. The clients becomes anxious whenever the clinical officer leaves the bedside
- D. The client looks at the shadow on a wall and tells the clinical officer she sees frightening faces on the wall
Correct Answer: D
Rationale: An illusion involves misinterpreting a real stimulus (e.g., seeing faces in a shadow), unlike hallucinations, which involve perceiving something not present.
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Schizophrenia in children as young as 5 years:
- A. Is a myth
- B. Can occur
- C. Never occurs
- D. Cannot occur
Correct Answer: B
Rationale: The correct answer is B: Can occur. Schizophrenia can indeed manifest in children as young as 5 years old, although it is rare. Symptoms may include hallucinations, delusions, disorganized speech, and impaired social interactions. Early diagnosis and intervention are crucial for managing the condition. Choice A is incorrect as schizophrenia in young children is not a myth. Choice C is incorrect as schizophrenia can occur in children. Choice D is incorrect as there have been documented cases of schizophrenia in children as young as 5 years old.
When told that he is scheduled to interview a patient with narcissistic personality disorder, the nurse can anticipate the assessment findings will include the following:
- A. charm, drama, seductiveness, and admiration seeking.
- B. preoccupation with minute details and perfectionism.
- C. difficulty being alone, indecisiveness, and submissiveness.
- D. grandiosity, self-importance, and a sense of entitlement.
Correct Answer: D
Rationale: The correct answer is D. In narcissistic personality disorder, individuals exhibit grandiosity, self-importance, and a sense of entitlement. This is a key feature of the disorder where individuals have an inflated sense of their own importance and require excessive admiration. This behavior is often accompanied by a lack of empathy and exploitation of others.
Choice A (charm, drama, seductiveness, and admiration seeking) is more characteristic of histrionic personality disorder.
Choice B (preoccupation with minute details and perfectionism) is more characteristic of obsessive-compulsive personality disorder.
Choice C (difficulty being alone, indecisiveness, and submissiveness) does not align with the typical presentation of narcissistic personality disorder.
Which symptom reported by a client, age 35, who was sexually abused as a child reflects the diagnosis of posttraumatic stress disorder (PTSD)?
- A. Reexperiencing the traumatic event
- B. Refusing to go to public places from which escape may be difficult
- C. Seeking advice and guidance prior to making any significant decision
- D. Ruminating over the abuse with friends and acquaintances
Correct Answer: A
Rationale: The correct answer is A: Reexperiencing the traumatic event. This symptom is a key criterion for diagnosing PTSD according to the DSM-5. It includes flashbacks, nightmares, or intrusive thoughts related to the traumatic event. This symptom indicates that the client is experiencing distressing memories of the past abuse, which is a common feature of PTSD.
Choice B is incorrect because it describes agoraphobia, a separate anxiety disorder, not specific to PTSD. Choice C is incorrect as seeking advice is not a diagnostic criterion for PTSD. Choice D is incorrect because ruminating over the abuse with others may reflect coping mechanisms or seeking support, but it does not necessarily indicate PTSD.
A nursing colleague says, 'This patient was admitted claiming to have been raped by her boyfriend, but just look at the sexy clothes she's wearing.' Which response reflects an understanding of the most likely source of the colleague's comment?
- A. Have you ever cared for other sexual assault victims?'
- B. Your sister was raped when she was in college, wasn't she?'
- C. You have three unmarried brothers about the patient's age, don't you?'
- D. Do you think that wearing sexy clothes caused her to be sexually assaulted?'
Correct Answer: D
Rationale: The correct answer is D because it addresses the underlying misconception that a person's clothing choices can justify or provoke sexual assault. By asking if the colleague believes the victim's clothing caused the assault, it challenges victim-blaming and highlights the importance of understanding consent and boundaries.
Option A does not directly address the colleague's potentially victim-blaming statement. Option B brings up the colleague's personal experience, which is irrelevant and may not effectively challenge the problematic comment. Option C makes assumptions about the colleague's personal life, which is not relevant to the situation at hand.
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 asked about his parents, the child reluctantly reveals that he thinks his father does not like him very much because he calls him 'stupid' and says he can never do anything right. This should be assessed as:
- A. physical abuse.
- B. sexual abuse.
- C. emotional abuse.
- D. economic abuse.
Correct Answer: C
Rationale: Explanation:
C: Emotional abuse is the correct assessment as the father's behavior of calling the child 'stupid' and criticizing him can cause psychological harm. This behavior undermines the child's self-esteem and mental well-being. The child's reluctance to speak about his parents also indicates emotional distress.
Incorrect choices:
A: Physical abuse involves causing physical harm, which is not evident in the scenario.
B: Sexual abuse involves inappropriate sexual behavior, which is not indicated in the scenario.
D: Economic abuse involves financial control or exploitation, which is not the primary issue in this scenario.