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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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The wife of a patient diagnosed with paranoid schizophrenia asks: “I’ve been told that my husband’s illness is probably related to imbalanced brain chemicals. Can you be more specific?”
- A. Breakdown of dopamine produces LSD, which in large amounts produces psychosis
- B. Decreased amounts of the brain chemical dopamine explain the presence of delusions and hallucinations.
- C. An increase in the brain chemical dopamine explains the presence of delusions and hallucinations.
- D. An increase in the brain chemical dopamine explains the presence of lack of motivation and disordered affect
Correct Answer: C
Rationale: The correct answer is C: An increase in the brain chemical dopamine explains the presence of delusions and hallucinations. In paranoid schizophrenia, there is an overactivity of dopamine receptors in the brain, leading to an excess of dopamine. This excess dopamine is associated with symptoms like delusions and hallucinations. Therefore, an increase in dopamine levels is directly linked to these specific symptoms in individuals with paranoid schizophrenia.
Explanation for why the other choices are incorrect:
A: Breakdown of dopamine producing LSD does not directly relate to the symptoms of paranoid schizophrenia.
B: Decreased amounts of dopamine do not explain the presence of delusions and hallucinations in paranoid schizophrenia; it is the increase in dopamine that is associated with these symptoms.
D: An increase in dopamine is more closely related to delusions and hallucinations rather than lack of motivation and disordered affect in paranoid schizophrenia.
When differentiating between bereavement symptoms and depression, the nurse will base the formulation on knowledge that in bereavement:
- A. Symptoms remit and exacerbate.
- B. Guilt feelings are overwhelming.
- C. Suicide thoughts are common.
- D. Psychomotor retardation is obvious.
Correct Answer: A
Rationale: The correct answer is A because in bereavement, symptoms of grief and sadness tend to come and go, known as remitting and exacerbating, as the individual processes the loss over time. This is a normal part of the grieving process. On the other hand, in depression, symptoms are persistent and may not improve without intervention. Guilt feelings being overwhelming (B) is common in both bereavement and depression. Suicide thoughts being common (C) can occur in severe depression but are not a distinguishing factor between bereavement and depression. Psychomotor retardation being obvious (D) is a symptom more commonly associated with severe depression rather than bereavement.
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.
A patient diagnosed with major depression has lost 20 pounds in one month, has chronic low self-esteem, and a plan for suicide. The patient has taken an antidepressant medication for 1 week. Which nursing intervention has the highest priority?
- A. Implement suicide precautions.
- B. Offer high-calorie snacks and fluids frequently
- C. Assist the patient to identify three personal strengths.
- D. Observe the patient for therapeutic effects of antidepressant medication.
Correct Answer: A
Rationale: The correct answer is A: Implement suicide precautions. This is the highest priority because the patient has a plan for suicide, which poses an immediate risk to their safety. Implementing suicide precautions involves ensuring the patient's environment is safe, removing any potential means of self-harm, and closely monitoring the patient to prevent any suicide attempts.
Choice B is incorrect because offering high-calorie snacks and fluids frequently addresses the physical aspect of weight loss but does not address the immediate safety concern of suicide.
Choice C is incorrect because assisting the patient to identify personal strengths is important for building self-esteem but is not the highest priority when the patient is at risk for suicide.
Choice D is incorrect because observing the patient for therapeutic effects of antidepressant medication is important but not as urgent as ensuring the patient's safety in the case of suicidal ideation.
Which statement best defines the nurse’s initial role as the patient’s source of help in addressing interpersonal problems?
- A. “I’ll work with your doctor to help you get better.”
- B. “I’ll be working with you to help solve your marital troubles.”
- C. “Your medications will help you feel better as soon as they take effect.”
- D. To direct the patient to other professionals for addressing interpersonal issues
Correct Answer: B
Rationale: The correct answer is B because it emphasizes the nurse's role in actively working with the patient to address interpersonal problems. The nurse's initial role is to provide support and assistance to the patient in resolving their issues collaboratively. Choice A focuses on medical treatment and collaboration with the doctor, not specifically addressing interpersonal problems. Choice C solely emphasizes the role of medications in improving the patient's well-being, neglecting the interpersonal aspect. Choice D suggests passing off the responsibility to other professionals, which contradicts the nurse's initial role as a source of help for the patient. In summary, choice B is correct because it highlights the nurse's active involvement in solving the patient's interpersonal problems.