Nokea
The nurse is caring for a client diagnosed with severe intellectual disability. Which of the following characteristics should the nurse recognize to be associated with severe intellectual disability?
- A. The client can perform some self-care activities independently.
- B. The client has advanced speech development.
- C. Other than possible coordination problems,the client's psychomotor skills are not affected.
- D. The client communicates wants and needs by "acting out" behaviors.
Correct Answer: D
Rationale: The correct answer is D because individuals with severe intellectual disability often have limited communication skills and may resort to "acting out" behaviors to express their wants and needs. This is a characteristic commonly associated with severe intellectual disability.
A: The client can perform some self-care activities independently - This is unlikely in severe intellectual disability as individuals typically have limitations in self-care abilities.
B: The client has advanced speech development - Individuals with severe intellectual disability often have significant delays in speech development.
C: Other than possible coordination problems, the client's psychomotor skills are not affected - Individuals with severe intellectual disability commonly have deficits in both cognitive and motor skills.
E, F, G: No additional choices provided for analysis.
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During a group therapy meeting,a client brings up a concern about the cleanliness of the bathroom. The nurse asks the group what should be done about the issue and how to resolve it. The nurse is demonstrating which type of leadership style?
- A. Laissez-faire
- B. Surrogate
- C. Autocratic
- D. Democratic
Correct Answer: D
Rationale: The correct answer is D: Democratic. In a democratic leadership style, the leader involves group members in decision-making. In this scenario, the nurse is asking the group for input and involving them in the process of resolving the issue, which aligns with the democratic approach. This empowers the group members to participate in finding a solution and promotes teamwork.
A: Laissez-faire is incorrect because in this style, the leader is hands-off and does not provide much guidance or direction.
B: Surrogate is incorrect as it refers to a substitute leader who takes over temporarily.
C: Autocratic is incorrect because in this style, the leader makes decisions without consulting the group.
Overall, the democratic leadership style is the most suitable for fostering collaboration and addressing group concerns effectively in this context.
Which of the following factors may contribute to an increased risk of suicide?
- A. Engaging in regular physical exercise
- B. Having a positive self-esteem
- C. Having a strong social support system
- D. Experiencing a history of trauma or abuse
Correct Answer: D
Rationale: The correct answer is D: Experiencing a history of trauma or abuse. Research shows that individuals who have experienced trauma or abuse are at a higher risk of suicide due to the psychological impact of such experiences. Trauma can lead to feelings of hopelessness, worthlessness, and despair, increasing suicidal ideation. Now, let's analyze why the other choices are incorrect. A: Engaging in regular physical exercise can actually reduce the risk of suicide by improving mental health and overall well-being. B: Having a positive self-esteem is also a protective factor against suicide as it fosters resilience and coping skills. C: Having a strong social support system is crucial in preventing suicide, as it provides emotional support and a sense of belonging, therefore decreasing the risk.
A nurse is caring for a client who is experiencing a manic episode. Other clients begin to complain about her disruptive behavior on the unit. Which of the following actions should the nurse take?
- A. Warn the client that further disruptions will result in seclusion.
- B. Ask the client to recommend consequences for her disruptive behavior.
- C. Set limits on the client's behavior and be consistent in approach.
- D. Ignore the client's behavior,realizing it is consistent with her illness.
Correct Answer: C
Rationale: The correct answer is C: Set limits on the client's behavior and be consistent in approach. This is the best course of action because it maintains a therapeutic environment while ensuring the safety and well-being of all clients. By setting limits, the nurse establishes boundaries for acceptable behavior during the manic episode, helping to prevent harm and maintain order on the unit. Consistency in approach is crucial to provide the client with structure and predictability, which can help manage the manic symptoms and reduce potential disruptions.
Choice A is not the best option as it may escalate the situation and does not address the underlying issue. Choice B is not appropriate as it puts the responsibility on the client to determine consequences, which may not be effective in managing the behavior. Choice D is incorrect as ignoring the behavior can compromise the safety of other clients and is not a therapeutic approach to managing manic episodes.
A client has made the decision to leave her alcoholic husband and reports feeling very depressed. Which of the following is a non-therapeutic statement by the nurse that demonstrates sympathy?
- A. You are feeling very depressed. I felt the same way when I decided to leave my husband.
- B. I can understand you are feeling depressed. It was a difficult decision. I'll sit with you.
- C. You seem depressed. It was a difficult decision to make. Would you like to talk about it?
- D. I know this is a difficult time for you. Would you like medication for anxiety?
Correct Answer: A
Rationale: The correct answer is A because the nurse is sharing her personal experience, which is not therapeutic as it shifts the focus from the client to the nurse's own experience. This can make the client feel unheard and invalidated. Choice B demonstrates empathy and offers support by acknowledging the client's feelings and offering to sit with them. Choice C also shows empathy and provides an opportunity for the client to talk. Choice D is non-therapeutic as it jumps to suggesting medication without exploring the client's emotions or needs.
A nurse is assessing a client diagnosed with schizophrenia who has been treated with fluphenazine (Prolixin) for several years. Which of the following findings should the nurse document as manifestations of tardive dyskinesia (TD)?
- A. Sudden onset of high fever
- B. Twisting tongue movements
- C. Constant tapping of feet when sitting
- D. Shuffling gait
Correct Answer: B
Rationale: Twisting tongue movements are a classic sign of tardive dyskinesia from long-term antipsychotic use.