Nokea
The nurse is discussing the need for early diagnosis and treatment of autism spectrum disorder (ASD) with parents of children suspected of having the condition. Which statement should the nurse include?
- A. Early diagnosis and treatment provide the only means for a cure of ASD.
- B. Early diagnosis and treatment gives your child the best chance of becoming a fully functioning adult.
- C. Early diagnosis and treatment provides the best way to ensure that your child can be admitted to an assisted living facility as an adult.
- D. Early diagnosis and treatment prevent your child from developing any other mental condition.
Correct Answer: B
Rationale: The correct statement for the nurse to include is that early diagnosis and treatment provide the best chance for the child to become a fully functioning adult. It is important to educate parents that while early intervention can improve outcomes for individuals with ASD, it does not offer a cure but helps in managing symptoms and developing necessary skills. Choice A is incorrect as there is currently no cure for ASD. Choice C is inaccurate as early diagnosis and treatment focus on improving the child's quality of life and independence rather than ensuring admission to an assisted living facility. Choice D is incorrect as early diagnosis and treatment of ASD do not prevent the development of other mental health conditions; however, they can help in identifying and managing such conditions early on.
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A client is diagnosed with schizophrenia. A physician orders haloperidol (Haldol) 50 mg bid, benztropine (Cogentin) 1 mg prn, and zolpidem (Ambien) 10 mg HS. Which client behavior would warrant the nurse to administer benztropine?
- A. Tactile hallucinations
- B. Tardive dyskinesia
- C. Restlessness and muscle rigidity
- D. Reports of hearing disturbing voices
Correct Answer: C
Rationale: Benztropine (Cogentin) is an anticholinergic medication used to treat extrapyramidal symptoms, such as restlessness and muscle rigidity, which are common side effects of antipsychotic medications like haloperidol. Tactile hallucinations and reports of hearing disturbing voices are symptoms of schizophrenia that would typically be addressed by the antipsychotic medication (haloperidol) itself. Tardive dyskinesia, a potential side effect of long-term antipsychotic use, would require discontinuation of the antipsychotic medication rather than administration of benztropine.
As a nursing supervisor in a long-term care facility, you prioritize strict infection control prevention measures due to the understanding that the normal aging process weakens the body's defenses. Which theory of aging supports the necessity of strict infection control prevention measures?
- A. The Programmed Longevity Theory
- B. The Immunological Theory of Aging
- C. The Endocrine Theory
- D. The Rate of Living Theory
Correct Answer: B
Rationale: The theory of aging that aligns with the need for strict infection control prevention measures is the Immunological Theory of Aging. This theory posits that aging leads to a decline in the body's immune defenses and a reduced ability of antibodies to protect against infections. The other theories do not directly address the impact of aging on the immune system. The Programmed Longevity Theory focuses on genetic changes affecting aging, the Endocrine Theory emphasizes hormonal changes, and the Rate of Living Theory relates longevity to the rate of oxygen metabolism.
Which of the following is an example of intrapersonal conflict?
- A. A nurse feels guilty when she administers essential medication that causes a client to have nausea and vomiting
- B. A nurse is called to testify in court about a client she cared for three years ago
- C. A nurse feels guilty for working overtime
- D. A nurse faces a conflict with a colleague over patient care decisions
Correct Answer: A
Rationale: Intrapersonal conflict involves negative feelings or frustrations within oneself. It may be related to decisions or actions that clash with personal morals or beliefs. Choice A is the correct answer because the nurse is experiencing guilt due to administering medication that causes a client to have negative side effects, which reflects an internal struggle. Choices B, C, and D do not represent intrapersonal conflict. Choice B involves a legal obligation, Choice C is related to external factors like working overtime, and Choice D pertains to a conflict with a colleague.
You have noticed that the last several patients you have cared for have had questionable blood pressure readings from their arterial lines. When checked against cuff pressures, a discrepancy has been noted, and further investigation has revealed faulty transducers. This is not the first product issue with this company. What positive step could you take to help resolve this situation?
- A. Use the old stock from a previous company
- B. Verify the cuff pressures every hour to ensure accuracy
- C. Notify the risk manager
- D. Form a peer workgroup to evaluate new products
Correct Answer: D
Rationale: Forming a peer workgroup to evaluate new products would be an excellent opportunity for collaboration among peers, management, and the purchasing department. When clinicians are engaged to work toward solutions that address patient care issues, they experience more empowerment and control over their work environments.
Choice A is incorrect because using old stock from a previous company does not address the root cause of the faulty transducers from the current company. Choice B is incorrect as verifying cuff pressures every hour does not directly address the issue of faulty transducers. Choice C is less effective than forming a peer workgroup as it involves only notifying the risk manager without involving a collaborative effort to resolve the product issue.
What might be signaled when a client tells the nurse to 'pray for me' and entrusts her wedding ring to the nurse?
- A. Anxiety
- B. Suicidal ideation
- C. Major depression
- D. Hopelessness
Correct Answer: B
Rationale: The client entrusting the wedding ring and asking the nurse to pray for them can be indicative of suicidal ideation. This behavior suggests a deep level of distress and hopelessness, potentially leading to suicidal thoughts or actions. While anxiety is a common emotion, the act of entrusting personal items and making requests like praying for them go beyond typical anxiety symptoms. Major depression can be associated with suicidal ideation, but the specific actions described in this scenario point more towards suicidal thoughts. Hopelessness, while related to suicidal ideation, is a broader concept that does not capture the specific cues given by the client in this scenario, making it a less accurate choice.