Nokea
The nurse is considering making a child abuse or neglect report to protective services. To make the report, the nurse needs to:
- A. Obtain the supervisor's permission to make the report
- B. Have strong evidence that the abuse/neglect has occurred
- C. Notify the parents of the intent to file the report
- D. Have suspicions that the abuse has occurred
Correct Answer: D
Rationale: The correct answer is D because mandatory reporting laws typically require healthcare professionals to report suspected cases of child abuse or neglect. Having suspicions that abuse has occurred is sufficient to make a report, as it is the responsibility of the healthcare provider to protect the child's safety. Obtaining the supervisor's permission (choice A) may delay the report unnecessarily. Having strong evidence (choice B) is not necessary for making a report, as suspicions should be reported for further investigation. Notifying the parents (choice C) may jeopardize the safety of the child if the abuser is aware of the report.
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A community mental health nurse receives a new client for his caseload. The diagnosis of the client is residual schizophrenia. Documentation states that the client has a number of negative symptoms. Which symptom would the nurse expect to assess in the client?
- A. Bizarre, somatic delusions
- B. Disorganized speech pattern
- C. Catatonic posturing
- D. Emotional blunting
Correct Answer: D
Rationale: The correct answer is D: Emotional blunting. In residual schizophrenia, negative symptoms involve deficits in normal emotional responses and behaviors. Emotional blunting refers to a reduction in the intensity of emotional expression, which is commonly seen in clients with residual schizophrenia. This symptom can include a lack of facial expressions, reduced vocal inflections, and overall flat affect.
Choice A (Bizarre, somatic delusions) is incorrect as it refers to a positive symptom of schizophrenia involving distorted beliefs about the body.
Choice B (Disorganized speech pattern) is incorrect as it is characteristic of disorganized schizophrenia, not residual schizophrenia.
Choice C (Catatonic posturing) is incorrect as it is a symptom of catatonic schizophrenia, not residual schizophrenia.
Your pregnant patient has a history of major depression. Which of the following is she most likely to be at risk for?
- A. She is at risk for development of manic episodes.
- B. She is at risk for recurrence of depression after the birth of the baby.
- C. She is more likely to have an autistic child.
- D. She has no higher risk for emotional problems than other patients.
Correct Answer: B
Rationale: History of major depression (B) is the biggest risk factor for postpartum depression, increasing the likelihood of recurrence post-delivery.
The nurse is aware, when developing a care plan, that the three major goals of care for the client in whom Alzheimer's disease has been diagnosed include providing for the client's safety and well-being, therapeutically managing the client's behaviors, and:
- A. Supporting the client during curative care.
- B. Providing support for family, relatives, and caregivers.
- C. Arranging for nursing home placement.
- D. None of the above.
Correct Answer: B
Rationale: The correct answer is B. Providing support for family, relatives, and caregivers is crucial in the care of a client with Alzheimer's disease as it helps to ensure a holistic approach to care. Family members and caregivers often experience significant stress and burden in caring for someone with Alzheimer's, so providing support to them can improve the overall quality of care for the client. Additionally, involving family and caregivers in the care plan can help in maintaining continuity and consistency in the client's care.
Other choices are incorrect because:
A: Supporting the client during curative care is not applicable in Alzheimer's disease as there is currently no cure for the condition.
C: Arranging for nursing home placement may be necessary in some cases, but it is not one of the three major goals of care for a client with Alzheimer's disease.
D: None of the above is incorrect as providing support for family, relatives, and caregivers is a critical aspect of care for clients with Alzheimer's disease.
A community health nurse visits an elderly person whose spouse died 6 months ago. Two vodka bottles are in the trash. When the nurse asks about alcohol use, this person says, 'I get lonely and drink a little to help me forget.' Select the nurses most therapeutic intervention.
- A. Assess whether this patient is drinking and driving
- B. Advise the person not to drink alone because the risks for injury increase
- C. Teach the person about risks for alcoholism and suggest other coping strategies
- D. Arrange for the person to attend an Alcoholics Anonymous meeting for older adults
Correct Answer: D
Rationale: This person needs help with alcohol abuse as well as social involvement. An AA meeting for older adults will provide an opportunity for peer bonding as well as strategies for coping with stress without abusing alcohol. The distracters will not be therapeutic in this instance.
A 25-year-old individual was brought by ambulance to the emergency room. The patient's sensorium alternates between clouded and clear, and the patient becomes agitated both physically and verbally when approached. The patient's cognitive impairment is most consistent with:
- A. Delirium
- B. Dementia
- C. Sundown syndrome
- D. Early-onset Alzheimer disease
Correct Answer: A
Rationale: The correct answer is A: Delirium. Delirium is characterized by acute onset, fluctuating course, altered level of consciousness, and cognitive impairment. In this case, the patient's alternating sensorium and agitation suggest an acute confusional state, which is typical of delirium. Delirium is often caused by underlying medical conditions, medications, or substance abuse.
Summary of other choices:
B: Dementia is a chronic, progressive cognitive decline that does not typically present with acute onset and fluctuating symptoms like delirium.
C: Sundown syndrome refers to worsening of symptoms in the evening and is often seen in patients with dementia, not in this acute and fluctuating presentation.
D: Early-onset Alzheimer's disease is a form of dementia that typically has a more insidious onset and does not present with acute fluctuations in cognition like delirium.