Nokea
The intervention of highest priority for a client with stage 3 Alzheimer's disease is to:
- A. Provide a stimulating environment
- B. Maintain hydration and nutrition
- C. Set limits on behavioral disinhibition
- D. Promote self-care activities
Correct Answer: B
Rationale: The correct answer is B because maintaining hydration and nutrition is crucial for the client's overall well-being and health in stage 3 Alzheimer's. Dehydration and malnutrition can lead to serious complications. Providing a stimulating environment (choice A) may be beneficial but not the highest priority. Setting limits on behavioral disinhibition (choice C) may be challenging due to the progression of the disease. Promoting self-care activities (choice D) may not be feasible as the client's cognitive abilities decline. Maintaining hydration and nutrition is essential for the client's survival and quality of life.
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An 11-year-old child stays home from school to care for his siblings while his mother works, is demeaned by his father, and has negative self-perceptions. Which intervention(s) would be appropriate? Select all that apply.
- A. Crisis intervention
- B. Create a safety plan.
- C. Refer to family therapy.
- D. Refer for case management.
Correct Answer: A
Rationale: The correct answer is A: Crisis intervention. This is appropriate because the child is experiencing multiple stressors that require immediate support. Crisis intervention focuses on providing immediate assistance to individuals in distress and can help address the child's current emotional and psychological needs.
Summary of other choices:
B: Creating a safety plan may be relevant if there are safety concerns, but it does not address the child's emotional well-being.
C: Referring to family therapy may be beneficial in addressing family dynamics, but it may not be the most urgent intervention in this case.
D: Referring for case management is important for coordinating services, but it may not provide the immediate emotional support needed in this situation.
Which of the following signs indicates that a patient with an eating disorder may need immediate hospitalization?
- A. Serum potassium level of 3.2 mEq/L
- B. Body mass index (BMI) of 18.5
- C. Noncompliance with meal plans
- D. Low energy and fatigue
Correct Answer: A
Rationale: The correct answer is A: Serum potassium level of 3.2 mEq/L. This indicates severe hypokalemia, which can lead to life-threatening cardiac arrhythmias in patients with eating disorders. Hospitalization is necessary for immediate monitoring and intervention to prevent serious complications. Choices B, C, and D do not indicate imminent life-threatening risks requiring immediate hospitalization.
A woman, abducted and raped at gunpoint by an unknown assailant, was found confused and disoriented. The nurse makes these observations about the patient: talking rapidly in disjointed phrases, unable to concentrate, indecisive when asked to make simple decisions. What is the patient's level of anxiety?
- A. Weak
- B. Mild
- C. Moderate
- D. Severe
Correct Answer: D
Rationale: The correct answer is D: Severe. The patient's symptoms of talking rapidly, inability to concentrate, and indecisiveness are indicative of severe anxiety. Rapid speech and disjointed phrases suggest heightened arousal, while the inability to concentrate and make decisions point to severe impairment in cognitive functioning. These symptoms align with the DSM-5 criteria for severe anxiety, which includes extreme levels of distress and impairment in daily functioning. Weak (A), mild (B), and moderate (C) levels of anxiety would not typically manifest in such severe cognitive and behavioral symptoms.
Assist her in developing an emergency plan, since the pattern of violence is likely to continue.
- A. Developing an emergency plan is crucial in situations of potential violence.
- B. The pattern of violence may decrease over time.
- C. The pattern of violence is unpredictable.
- D. None of the above.
Correct Answer: A
Rationale: Rationale for Choice A:
1. Developing an emergency plan is crucial as it ensures safety during potential violent situations.
2. It empowers the individual to have a plan of action in place to protect themselves.
3. By having an emergency plan, the individual can respond quickly and effectively to ensure their safety.
Summary of Other Choices:
B. The pattern of violence decreasing is uncertain and doesn't address the immediate need for safety.
C. Labeling the pattern of violence as unpredictable doesn't provide a proactive solution for the individual's safety.
D. "None of the above" is incorrect as developing an emergency plan is a proactive and necessary step in situations of potential violence.
A 10-year-old boy presents with a history of central abdominal pain of a few hours' duration. On examination he has minimal tenderness in the right iliac fossa and no abnormal findings on rectal examination. Which of the following alternatives should be carried out?
- A. Arrange a barium meal follow through.
- B. Arrange to see the patient later on in the day for review.
- C. Send the patient away with instructions to return if the pain becomes worse.
- D. Tell the patient to come back in a week.
Correct Answer: B
Rationale: Early appendicitis can present subtly. Minimal right iliac fossa tenderness warrants observation, so reviewing later (B) is appropriate. Imaging (A), dismissal (C, D), or immediate surgery (E) without further assessment are not justified yet.