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The nurse is assessing a child with autism. Which of the following behaviors would the nurse expect to observe?
- A. Referring to their imaginary friend, Skipper
- B. Asking to telephone my friends on the weekends
- C. Repeating, milk, milk, milk, milk until given a drink.
- D. Is insistent that a dim light be left on in the bedroom at night
Correct Answer: C
Rationale: The correct answer is C: Repeating, milk, milk, milk, milk until given a drink. This behavior is a characteristic of children with autism, known as echolalia. Echolalia is the repetition of words or phrases spoken by others, often used by individuals with autism to communicate or self-soothe. This behavior is a common feature of autism spectrum disorder and is indicative of language difficulties and communication challenges.
Choices A, B, and D are incorrect because they do not specifically relate to behaviors typically observed in children with autism. Referring to an imaginary friend (A) is not exclusive to autism, asking to telephone friends on weekends (B) is a social behavior that can be seen in children without autism, and insisting on a dim light in the bedroom (D) is a preference that does not directly relate to the core characteristics of autism.
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Which nursing intervention supports the principles on which the cross-links theory of aging is based?
- A. Applying an elastin-sustaining moisturizer to an adult patient’s skin
- B. Assessing a patient’s family history for genetic diseases and disorders
- C. Questioning a patient about long-term exposure to environmental toxins
- D. Assisting an adult patient in selecting foods high in vitamins A, C, and E
Correct Answer: D
Rationale: The correct answer is D because selecting foods high in vitamins A, C, and E supports the principles of the cross-links theory of aging, which focuses on the accumulation of damage from oxidative stress. Vitamins A, C, and E are antioxidants that help combat oxidative stress and reduce the formation of cross-links in tissues. This intervention can potentially slow down the aging process by reducing cellular damage.
Choice A is incorrect because applying an elastin-sustaining moisturizer does not directly address the oxidative stress aspect of the cross-links theory of aging.
Choice B is incorrect as assessing family history for genetic diseases does not specifically target the mechanisms involved in the cross-links theory of aging.
Choice C is incorrect because questioning about exposure to environmental toxins may be important for overall health but is not directly related to the principles of the cross-links theory of aging.
An elderly couple who lived in the same home for the past 50 years have moved into an
adult retirement center in a nearby town. Changes in lifestyle such as this couple is
experiencing should alert the nurse to the possibility of:
- A. Acute grief
- B. Traumatic grief
- C. Chronic sorrow
- D. Adventitious crisis
Correct Answer: D
Rationale: The correct answer is D: Adventitious crisis. This type of crisis is triggered by external events such as moving to a retirement center after 50 years in the same home. The sudden change in environment can lead to distress and challenges for the elderly couple, causing an adventitious crisis. Acute grief (A) and traumatic grief (B) are typically associated with the loss of a loved one, not a change in lifestyle. Chronic sorrow (C) refers to ongoing grief related to a chronic illness or disability, which is not the case in this scenario.
A woman whose abusive husband was killed in an automobile accident 3 years earlier continues to idealize him and repeatedly talks about their “wonderful relationship.” Which outcome is most appropriate for the patient? Patient will:
- A. Enlist the emotional support of both family and friends.
- B. Keep a daily journal recording memories of time spent with her husband.
- C. Express both positive and negative feelings about her husband and their life together.
- D. Read information on the affects of physical abuse and the support groups available to her.
Correct Answer: C
Rationale: Rationale:
Choice C is correct because it encourages the patient to express both positive and negative feelings about her husband and their relationship. This approach helps the patient process complex emotions and move towards a more realistic view of the past. It promotes emotional healing and growth by allowing the patient to acknowledge and work through conflicting feelings.
Summary of Incorrect Choices:
A: While emotional support is important, simply enlisting the support of family and friends may not address the underlying issues of idealization and unresolved emotions.
B: Keeping a daily journal may reinforce the idealization of the husband and could potentially hinder the patient's progress in coming to terms with the reality of the relationship.
D: Reading about abuse and support groups may provide information, but it does not directly address the patient's need to explore and express her own feelings about her husband and their relationship.
A patient states, "I’m not worth anything. I have negative thoughts about myself. I feel anxious and shaky all the time. Sometimes I feel so sad that I want to go to sleep and never wake up." Which nursing intervention should have the highest priority?
- A. Self-esteem-building activities.
- B. Anxiety self-control measures.
- C. Sleep enhancement activities.
- D. Suicide precautions.
Correct Answer: D
Rationale: The correct answer is D: Suicide precautions. The patient's statement indicates they are experiencing severe depression and suicidal ideation. Suicide precautions should be the highest priority to ensure the patient's safety. This includes removing any potential means of self-harm, constant monitoring, and close supervision. Self-esteem-building activities (A) may be helpful in the long term but are not the immediate priority. Anxiety self-control measures (B) are important but addressing suicidal ideation takes precedence. Sleep enhancement activities (C) are also important but not the highest priority when dealing with suicidal thoughts.
The parents of an 8-year-old are attempting to help their child comprehend new information. Which intervention suggested by the nurse shows an understanding of the cognitive development theory for this age group?
- A. The use of drawing and illustrations
- B. Comparing the child’s experiences to the new material
- C. Encouraging the child to talk about this new information
- D. Asking the child to give a reason for how they feel about new information
Correct Answer: B
Rationale: The correct answer is B: Comparing the child’s experiences to the new material. At the age of 8, children are in the concrete operational stage according to Piaget's cognitive development theory. This stage is characterized by the ability to think logically about concrete events and understand the concept of conservation. By comparing the child's experiences to the new material, the parents are helping the child make connections between what they already know and the new information, which facilitates understanding. Drawing and illustrations (choice A) are helpful for visual learners but may not necessarily tap into the child's cognitive development stage. Encouraging the child to talk about new information (choice C) is beneficial for communication skills but may not directly address cognitive development. Asking the child to give a reason for how they feel about new information (choice D) focuses more on emotions rather than cognitive understanding.