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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 patient was admitted to the mental health unit after arguing with co-workers and threatening to kill them. He is diagnosed with paranoid schizophrenia. On the unit he is aloof and suspicious. He mentioned that two physicians he saw talking were plotting to kill him. On the basis of data gathered at this point, which two primary nursing diagnoses should the nurse consider?
- A. Disturbed thought processes and Risk for other-directed violence
- B. Spiritual distress and Social isolation
- C. Risk for loneliness and Knowledge deficit
- D. Disturbed personal identity and Nonadherence
Correct Answer: A
Rationale: The correct answer is A: Disturbed thought processes and Risk for other-directed violence.
1. Disturbed thought processes: The patient's delusion of being plotted against by the physicians indicates impaired thought processes typical of paranoid schizophrenia.
2. Risk for other-directed violence: The patient's threatening behavior towards co-workers suggests a potential for violent acts towards others due to his paranoid beliefs.
Summary of why other choices are incorrect:
B: Spiritual distress and Social isolation are not primary concerns given the patient's acute symptoms of paranoia and risk for violence.
C: Risk for loneliness and Knowledge deficit are not crucial at this point as the patient's primary issues are related to paranoia and violence.
D: Disturbed personal identity and Nonadherence are not relevant to the immediate safety and mental health concerns presented by the patient.
The quality of life of people with intellectual disabilities can be improved significantly with the help of basic training procedures that will equip them with a range of skills depending on their level of disability. The application of learning theory to training in these areas is also known as:
- A. Applied cognitive approaches
- B. Applied treatment analysis
- C. Cognitive behavioural therapy
- D. Applied behaviour analysis
Correct Answer: D
Rationale: Applied Behaviour Analysis: Applying principles of learning theory, particularly operant conditioning, to improve skills in individuals with intellectual disabilities.
The nurse who works in a sleep clinic knows that approximately __________% of adults experience some form of sleep disorder.
- A. 10 to 20.
- B. 30 to 40.
- C. 50 to 60.
- D. None of the above.
Correct Answer: B
Rationale: The correct answer is B (30 to 40%). This range is supported by research indicating that around 30-40% of adults experience some form of sleep disorder. This percentage reflects the prevalence of various sleep disorders such as insomnia, sleep apnea, and restless leg syndrome among adults. The range of 10 to 20% (choice A) is too low based on current data. Likewise, the range of 50 to 60% (choice C) is too high and does not align with the established prevalence rates of sleep disorders in adults. "None of the above" (choice D) is incorrect as there is a documented prevalence of sleep disorders in adults, making it necessary to provide an estimate within a certain range.
A 5-year-old boy is diagnosed in the Emergency Department as having measles, the first symptoms having started 2 days previously. He has a 2-year-old sister, who has received the recommended immunisation schedule. Which one of the following is the most appropriate treatment?
- A. Treat him symptomatically and send him home.
- B. Refer him to the infectious diseases hospital.
- C. Give him gamma globulin.
- D. Give gamma goblin to the sister.
Correct Answer: A
Rationale: Measles is managed symptomatically at home (A) unless complications arise. The vaccinated sister is protected, so hospitalization (B), gamma globulin (C, D), or premature reassurance (E) are unnecessary.
A 17-year-old client is admitted to the ED after being alternately hyperalert and difficult to arouse. His symptoms all started within the last few hours, during which time he became disoriented and confused. His behavior was agitated and restless, and his memory was impaired, especially for recent events. The client displayed some delusions and misinterpretations of his surroundings. The nurse knows she needs to assess the client further for:
- A. Dementia
- B. Depression
- C. Delirium
- D. Amnesia
Correct Answer: C
Rationale: The correct answer is C: Delirium. Delirium is characterized by acute and fluctuating changes in cognition, attention, and awareness. The client's sudden onset of symptoms, including disorientation, confusion, agitation, restlessness, impaired memory, delusions, and misinterpretations of surroundings, align with the hallmark features of delirium. The nurse needs to further assess the client for delirium to determine the underlying cause and provide appropriate interventions promptly.
Incorrect choices:
A: Dementia - Dementia is a chronic, progressive condition characterized by gradual cognitive decline. The client's acute onset of symptoms is not consistent with dementia.
B: Depression - Depression typically presents with persistent feelings of sadness, hopelessness, and loss of interest, which are different from the acute and fluctuating cognitive changes seen in delirium.
D: Amnesia - Amnesia refers to memory loss, which is only one aspect of the client's presentation. Delirium involves a broader range of cognitive