Nokea
The mother of a child describes her child's annoying behavior as not being able to sit still or to stop jerking his arms when told to. Which disorder does the nurse suspect?
- A. Oppositional-defiant disorder
- B. Tourette’s disorder
- C. Oppositional-defiant disorder
- D. What makes you think he is doing that out of defiance?
Correct Answer: B
Rationale: The correct answer is B: Tourette’s disorder. The child's inability to sit still and jerking arms suggest motor tics, which are common in Tourette's disorder. Tourette's is characterized by involuntary repetitive movements or sounds. Choice A is incorrect as oppositional-defiant disorder does not involve physical tics. Choice C is a duplicate. Choice D is incorrect as it assumes defiance rather than considering a neurological explanation for the behavior.
You may also like to solve these questions
Immediately after electroconvulsive therapy (ECT), nursing care of the patient is most similar to care of a patient:
- A. With delirium tremens
- B. Recovering from conscious sedation
- C. With acute alcohol withdrawal
- D. Undergoing a routine diagnostic procedure
Correct Answer: B
Rationale: The correct answer is B: Recovering from conscious sedation. After ECT, patients are closely monitored as they recover from anesthesia and sedation. Nursing care involves assessing vital signs, mental status, and ensuring the patient's safety. This is similar to caring for a patient recovering from conscious sedation, where monitoring and observation are essential.
A: Delirium tremens involves severe alcohol withdrawal symptoms, which require specialized care including managing agitation and hallucinations.
C: Acute alcohol withdrawal requires specific interventions such as monitoring for seizures and providing medications to prevent complications.
D: Routine diagnostic procedures do not typically involve sedation or anesthesia, so the level of monitoring and care needed is different from post-ECT care.
The highest priority for assessment by nurses caring for older adults who self-administer medications is:
- A. Use of multiple drugs with anticholinergic effects.
- B. Overuse of medications for erectile dysfunction.
- C. Missed doses of medications for arthritis.
- D. Trading medications with acquaintances.
Correct Answer: A
Rationale: The correct answer is A: Use of multiple drugs with anticholinergic effects. This is the highest priority as anticholinergic medications can have severe side effects in older adults, including confusion, constipation, and increased risk of falls. Nurses need to assess for potential harm caused by these medications.
Choice B (Overuse of medications for erectile dysfunction) is not the highest priority as it may not pose an immediate threat to the health and safety of older adults compared to anticholinergic effects.
Choice C (Missed doses of medications for arthritis) is important but not as critical as assessing for the potential harm caused by anticholinergic medications.
Choice D (Trading medications with acquaintances) is concerning but not as urgent as assessing for the harmful effects of anticholinergic medications, which can lead to serious health complications.
The nurse determines that the most effective point of intervention for bereavement is:
- A. Promotion of mental and spiritual health across the life spa
- B. At the time a newly discovered loss is impending
- C. Immediately after the loss has occurred
- D. When requested by the patient
Correct Answer: C
Rationale: The correct answer is C because intervening immediately after the loss has occurred allows for timely support and processing of emotions. This is crucial for healthy grieving and preventing complications. Choice A is too broad and not specific to the immediate need post-loss. Choice B focuses on pre-loss, which is not the most effective time for intervention. Choice D puts the responsibility on the patient, which may delay necessary support.
Which behaviors are reflective of legitimate phases of a group’s development? Select all that apply.
- A. Stating the goals of the group
- B. Establishing who will assume the leadership role
- C. Inviting family members to attend and provide their input
- D. Feeling safe enough to discuss painful personal situations
Correct Answer: A
Rationale: The correct answer is A because stating the goals of the group is reflective of the forming stage where members clarify the purpose and direction. Choice B is incorrect as determining leadership roles typically occurs during the storming stage. Choice C is incorrect as involving family members is not part of the group development process. Choice D is incorrect as discussing personal situations usually happens during the norming or performing stages, not in the initial forming stage.
A newly admitted patient diagnosed with major depression has gained 20 pounds over a few months and has suicidal ideation. The patient has taken an antidepressant medication for 1 week without remission of symptoms. Select the priority nursing diagnosis.
- A. Imbalanced nutrition: more than body requirements.
- B. Chronic low self-esteem.
- C. Risk for suicide.
- D. Hopelessness.
Correct Answer: C
Rationale: The priority nursing diagnosis in this case is C: Risk for suicide. This is because the patient is exhibiting suicidal ideation, which poses an immediate threat to their safety and well-being. Suicidal ideation requires urgent intervention to ensure the patient's safety. The patient's major depression, weight gain, and lack of symptom remission from the antidepressant medication further emphasize the seriousness of the situation. Choices A, B, and D are not the priority in this scenario as they do not address the immediate risk of harm to the patient. Imbalanced nutrition and chronic low self-esteem are important concerns but do not take precedence over the risk of suicide. Hopelessness, while relevant, is not as urgent as addressing the immediate risk of suicide.