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The nurse performs a functional assessment of a client upon admission to a home health agency. The purpose of this assessment is to determine the client's:
- A. Level of consciousness.
- B. Ability to perform activities of daily living.
- C. Degree of reasoning, judgment, and thought processes.
- D. None of the above.
Correct Answer: B
Rationale: Rationale:
1. Functional assessment evaluates client's ability to perform ADLs.
2. Assessing ADLs helps determine client's independence level.
3. Independence in ADLs impacts care planning and interventions.
4. Level of consciousness (A) is related to neurological status, not functional ability.
5. Reasoning, judgment (C) are cognitive functions, not directly related to ADLs.
6. "None of the above" (D) excludes the correct purpose of functional assessment.
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A psychiatric technician asks the nurse to explain the difference between schizotypal personality disorder and schizophrenia. The information that should serve as the basis for the nurse's response is the fact that with schizotypal personality disorder:
- A. There is greater personality disorganization than in schizophrenia
- B. There may be misinterpretation of events but not psychosis
- C. The client will be sicker and require longer hospitalization
- D. The client will be more outgoing, actively seeking interactions with others
Correct Answer: B
Rationale: The correct answer is B: There may be misinterpretation of events but not psychosis. In schizotypal personality disorder, individuals may have odd beliefs, behaviors, and experiences, leading to misinterpretation of events, but they do not typically experience full-blown psychosis as seen in schizophrenia. This is a key distinction between the two disorders. Choice A is incorrect because schizophrenia is characterized by more severe disorganization of thoughts and behaviors. Choice C is incorrect as individuals with schizotypal personality disorder typically do not require long hospitalizations compared to those with schizophrenia. Choice D is incorrect as individuals with schizotypal personality disorder tend to be more socially isolated and have difficulty forming close relationships.
A patient asks, 'What advantage does a durable power of attorney for health care have over a living will?' The nurse should reply, 'A durable power of attorney for health care:
- A. gives your agent authority to make decisions during any illness if you are incapacitated
- B. can be given only to a relative, usually the next of kin, who has your best interests at heart
- C. can be used only if you have a terminal illness and become incapacitated
- D. cannot be implemented until 30 days after the documents are signed
Correct Answer: A
Rationale: A durable power of attorney for health care is an instrument that appoints a person other than a health care provider to act as an individuals agent in the event that he or she is unable to make medical decisions. No waiting period is required for it to become effective, and the individual does not have to be terminally ill or incompetent for the person appointed to act on the individuals behalf.
A mother discusses her concerns about genetic transmission of schizophrenia with the nurse saying, 'My son is a fraternal twin. He has been diagnosed with schizophrenia. Will my other son develop schizophrenia, too?' The response that is both sensitive and shows understanding of the genetic component is:
- A. You poor woman! I wish I could tell you he will be free of the disorder.'
- B. Studies show that 50% of twins develop schizophrenia when it is present in the other twin.'
- C. No one can say what will happen, so we will hope for the best for you and your sons.'
- D. In fraternal twins, the chance of the other twin developing the disorder is quite small.'
Correct Answer: D
Rationale: The correct answer is D because it provides an accurate and sensitive response. Fraternal twins do not share the same genetic makeup as identical twins, so the genetic risk for the other twin developing schizophrenia is lower. By acknowledging this fact, the nurse offers reassurance to the mother without giving false hope or inaccurate statistics. This response shows understanding of the genetic component of schizophrenia and addresses the mother's concerns in a compassionate and informative manner.
Choices A, B, and C are incorrect:
A: This response is dismissive of the mother's concerns and does not provide any helpful information. It also lacks sensitivity and empathy towards the mother's situation.
B: This response provides an inaccurate statistic about the likelihood of the other twin developing schizophrenia. It does not consider the difference between identical and fraternal twins, leading to a potentially misleading statement.
C: This response is vague and does not address the mother's question directly. It does not provide any useful information or reassurance, leaving the mother uncertain and anxious about
How does peer interaction influence mental development?
- A. Increases stress
- B. Enhances problem-solving
- C. Limits creativity
- D. Reduces attention span
Correct Answer: B
Rationale: Peer interaction enhances problem-solving (B) by encouraging collaboration and critical thinking, a key aspect of mental development. It doesn't inherently increase stress (A), limit creativity (C), or reduce attention (D).
Prior to discharge, the nurse plans to teach the client and family about relapse. Which items will the nurse include in the teaching?
- A. Recognition of warning signs of relapse
- B. Notify the nurse of warning signs present for more than one month
- C. Lower medication dosage to manage emerging side effects
- D. Use street drugs judiciously and only in small amounts
Correct Answer: A
Rationale: The correct answer is A because recognizing warning signs of relapse is crucial for early intervention. By identifying these signs, the client and family can seek help promptly, preventing a full relapse. Choice B is incorrect as waiting for signs to persist for more than one month delays intervention. Choice C is incorrect as altering medication dosage without medical advice can be dangerous. Choice D is incorrect as using street drugs is never a safe or appropriate way to manage relapse.