Nokea
The subjective internal feeling of being either male of female is called
- A. Gender identity
- B. Sexuality
- C. Gender identity disorder
- D. Sexual orientation
Correct Answer: A
Rationale: Gender identity refers to one's internal sense of being male, female, or another gender, distinct from sexual orientation or physical traits.
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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.
A patient referred to the eating disorders clinic lost 35 pounds over 3 months. To assess eating patterns, the nurse should ask:
- A. Do you often feel fat?
- B. Who plans the family meals?
- C. What do you eat in a typical day?
- D. What do you think about your present weight?
Correct Answer: C
Rationale: Rationale:
C is correct because it directly addresses the assessment of eating patterns by inquiring about the patient's actual food intake. This question provides valuable information on the quantity and quality of food consumed, aiding in diagnosing and treating eating disorders.
Other choices are incorrect:
A is focused on body image and self-perception, not eating patterns.
B is about family dynamics, not the patient's individual eating habits.
D pertains to body weight perception, not the specifics of the patient's diet.
A 72-year-old patient has the medical diagnosis of delirium secondary to anticholinergic medication toxicity. Family members are very anxious and express their concerns about placing the patient in a nursing home. What information should serve as a basis for the nurse's reply?
- A. Delirium is reversible, and the patient will likely recover.
- B. The symptoms are related to depression, which can be treated.
- C. Delirium usually progresses to dementia, which is usually permanent.
- D. Home care should be attempted; a nursing home should be the last resort.
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. Delirium is an acute, reversible condition caused by underlying factors like medication toxicity.
2. By addressing the anticholinergic medication toxicity, the delirium can be resolved, leading to recovery.
3. The patient's age does not necessarily indicate a progression to dementia.
4. Placing the patient in a nursing home is not the immediate solution; resolving the toxicity should be the priority.
Summary:
Choice A is correct because delirium is reversible with appropriate treatment. Choices B, C, and D are incorrect because they do not address the underlying cause of delirium or provide accurate information about its progression or management.
An 83-year-old man becomes lost while driving. He pulls into a driveway to turn around and cannot figure out how to put his car in reverse, so he drives into the yard, makes a circle, and drives back out of the driveway. He is stopped by police, who take him to the emergency department. The physician diagnoses him with Alzheimer's disease and refers him to the neurology clinic for follow-up. Given this diagnosis, which behaviors should the clinic nurse anticipate?
- A. Does not know today's date.
- B. Unable to shower without help.
- C. Denial of mental impairment.
- D. None of the above.
Correct Answer: A
Rationale: The correct answer is A: Does not know today's date. This behavior is commonly associated with Alzheimer's disease due to memory impairment. The inability to recall the current date is a key symptom of cognitive decline. In this case, the man's difficulty with reversing his car and getting lost are indicative of cognitive impairment.
Choice B, Unable to shower without help, is a functional impairment and not specific to Alzheimer's disease. Choice C, Denial of mental impairment, may occur in some individuals with Alzheimer's but is not a consistent behavior. Choice D, None of the above, is incorrect as memory deficits, such as not knowing the date, are commonly seen in Alzheimer's disease.
The daughter of an 84-year-old client with dementia tearfully tells the nurse that she doesn't know what's wrong with her mother, who has begun accusing the family of stealing her lingerie and holding her prisoner. The nurse assesses the client's stage of Alzheimer's disease as stage:
- A. 1
- B. 2
- C. 3
- D. 4
Correct Answer: B
Rationale: The correct answer is B (stage 2) because the client is exhibiting symptoms of moderate Alzheimer's disease, such as paranoia and delusions. In stage 2, cognitive decline becomes more noticeable, leading to memory loss, confusion, and behavioral changes. The client's accusations and false beliefs indicate a decline in reality orientation, which is characteristic of stage 2. Choices A, C, and D are incorrect because stage 1 is characterized by mild cognitive decline, stage 3 by severe cognitive decline, and stage 4 by very severe cognitive decline.