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The nurse is assessing a child's cognitive ability to think logically. The nurse asks the child to count backward from 10 to 0, and the child complies. What cognitive stage is this child in?
- A. sensorimotor
- B. formal operational
- C. concrete operational
- D. preoperational
Correct Answer: C
Rationale: The child counting backward from 10 to 0 demonstrates conservation of numbers and reversibility, characteristics of the concrete operational stage. In this stage, children can engage in logical thought processes, manipulate information mentally, and understand conservation. This ability is typically developed around ages 7 to 11.
A: Sensorimotor stage focuses on sensory experiences and object permanence, typically occurring from birth to age 2.
B: Formal operational stage involves abstract thinking and hypothetical reasoning, usually from age 12 and beyond.
D: Preoperational stage includes egocentrism and lack of conservation, typical for children aged 2 to 7.
Therefore, the child counting backward is in the concrete operational stage due to their ability to think logically and understand conservation.
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While leading a group, a nurse leader says to a patient, 'This is the fourth time that you've changed the subject when we have talked about child abuse. Is something going on?' The nurse is using which technique?
- A. Support
- B. Confrontation
- C. Summarizing
- D. Clarification
Correct Answer: B
Rationale: The correct answer is B: Confrontation. In this scenario, the nurse leader directly addresses the patient's behavior of changing the subject, which is a key aspect of confrontation technique. Confrontation is used to address discrepancies or inconsistencies in a nonjudgmental manner to promote self-awareness and insight. This technique encourages the patient to explore their thoughts and behaviors.
Incorrect Choices:
A: Support - Support involves providing empathy, understanding, and validation to the patient. The nurse in the scenario is not offering support, but rather challenging the patient's behavior.
C: Summarizing - Summarizing involves restating key points to ensure understanding and facilitate communication. The nurse's statement does not summarize but rather confronts the patient's behavior.
D: Clarification - Clarification is used to ensure mutual understanding by seeking clarification on unclear statements. The nurse's statement is not seeking clarification but rather addressing a specific behavior pattern.
A person who has been unable to leave home for more than a week because of severe anxiety says, "I know it does not make sense, but I just can't bring myself to leave my apartment alone." Which nursing intervention is appropriate?
- A. Help the person use online video calls to provide interaction with others.
- B. Advise the person to accept the situation and use a companion.
- C. Ask the person to explain why the fear is so disabling.
- D. Teach the person to use positive self-talk techniques.
Correct Answer: D
Rationale: The correct answer is D, teaching the person to use positive self-talk techniques. This intervention is appropriate because it addresses the cognitive aspect of anxiety. By teaching the person to challenge negative thoughts and replace them with positive affirmations, they can gradually overcome their fear and build confidence in leaving the apartment. Online video calls (A) may provide temporary relief but do not address the root cause of the anxiety. Advising the person to use a companion (B) may enable avoidance of the problem rather than actively working on overcoming it. Asking the person to explain their fear (C) may not be helpful if they are already aware that it is irrational. Positive self-talk techniques empower the individual to change their mindset and behavior effectively.
A client on a psychiatric unit is telling the nurse about anger toward the airline after losing an only child in a plane crash. In which situation is the nurse demonstrating active listening?
- A. Agreeing with the client.
- B. Repeating everything that the client says to clarify.
- C. Assuming a relaxed posture and leaning toward the client.
- D. Expressing sorrow and sadness regarding the client's loss.
Correct Answer: C
Rationale: The correct answer is C because assuming a relaxed posture and leaning toward the client demonstrates active listening by showing empathy and interest in what the client is saying. This nonverbal behavior encourages the client to continue expressing their feelings.
A: Agreeing with the client can shut down communication and invalidate the client's emotions.
B: Repeating everything the client says may come across as robotic and not conducive to building rapport.
D: Expressing sorrow and sadness, while empathetic, may shift the focus from the client to the nurse's emotions.
In summary, actively listening involves nonverbal cues that show understanding and support without interjecting personal opinions or emotions.
Taylor, a psychiatric registered nurse, orients Regina, a patient with anorexia nervosa, to the room where she will be assigned during her stay. After getting Regina settled, the nurse informs Regina:
- A. I need to go through the belongings you have brought with you.
- B. You can use the scale in the back room when you need to.
- C. You will be eating five times a day here.
- D. The daily structure is based around your desire to eat.
Correct Answer: A
Rationale: The correct answer is A because as a psychiatric nurse, it is important to ensure the safety of the patient, especially those with anorexia nervosa who may have harmful items in their belongings. Going through the patient's belongings allows the nurse to assess and remove any potential risks. This action aligns with the duty of care and ensures the patient's well-being.
Choice B is incorrect because using a scale can trigger anxiety and reinforce unhealthy behaviors related to weight monitoring in patients with anorexia nervosa. Choice C is incorrect as stating a specific number of meals may not be suitable for every individual and could create unnecessary pressure on the patient. Choice D is incorrect because the structure of care should be based on evidence-based practices and clinical guidelines, not solely on the patient’s desire to eat.
The nurse is caring for a patient who has been under severe stress while caring for her elderly mother who is in the advanced stages of Alzheimer's disease. The nurse explains that the patient is adapting to the stress she is experiencing because of which of the following?
- A. Ability to survive in the midst of severe stress
- B. Acceptance of others'help in caring for her mother
- C. Success at being able to solve problems
- D. Capability in setting reasonable personal goals
Correct Answer: A
Rationale: Correct Answer: A: Ability to survive in the midst of severe stress
Rationale:
1. The patient is under severe stress due to caring for her mother with Alzheimer's disease.
2. Adaptation to stress involves the ability to survive and cope with challenging situations.
3. Surviving severe stress indicates the patient's resilience and ability to endure difficult circumstances.
4. This choice best reflects the patient's capacity to manage and withstand the stress she is facing.
Summary:
B: Acceptance of others' help in caring for her mother - This choice focuses on receiving help from others, which may not directly relate to the patient's ability to adapt to stress.
C: Success at being able to solve problems - While problem-solving skills are valuable, adaptation to stress goes beyond just solving problems.
D: Capability in setting reasonable personal goals - Setting goals is important but may not directly address the patient's adaptation to severe stress.