Nokea
The therapeutic approach in the care of an autistic child include the following EXCEPT:
- A. Engage in diversionary activities when acting out
- B. Provide an atmosphere of acceptance
- C. Provide safety measures
- D. Rearrange the environment to activate the child
Correct Answer: D
Rationale: Rearranging the environment to activate the child may overstimulate an autistic child, who typically benefits from consistency and calm settings.
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Which symptom of Alzheimer's disease is associated with disorientation to time and place?
- A. Forgetting in what order to put clothes on
- B. Forgetting simple words
- C. Forgetting where he or she lives
- D. Becoming suspicious of others
Correct Answer: C
Rationale: The correct answer is C: Forgetting where he or she lives. In Alzheimer's disease, disorientation to time and place is a common symptom due to memory loss and cognitive decline. Forgetting where one lives directly relates to disorientation, as the individual may not recognize their home or surroundings. Choice A is related to sequencing and executive function, not specific to time and place. Choice B is more associated with language and communication difficulties. Choice D relates to paranoia or mistrust, not specifically related to disorientation to time and place. In summary, the correct answer directly reflects the symptom of disorientation in Alzheimer's disease, while the other choices are related to different cognitive functions.
A patient whose boyfriend raped her during an argument tells the nurse, 'It's no use reporting it. No one will ever believe me, because everyone knows I've been sexually intimate with him many times before.' Which response by the nurse would have the greatest therapeutic value initially?
- A. You will need to talk to someone. Do you have a best friend to talk to?'
- B. It's not your fault. He needs to get help controlling his anger.'
- C. The police need to be aware that your boyfriend is willing to act this way when he's angry.'
- D. If you said 'no,' your boyfriend needs to respect your wishes. He needs help so this will never happen again.'
Correct Answer: D
Rationale: Rationale for Correct Answer D:
1. Acknowledges the patient's agency and emphasizes consent.
2. Validates the patient's experience and emphasizes boundaries.
3. Encourages the patient to prioritize her safety and well-being.
4. Addresses the need for intervention and prevention of future harm.
Summary:
A: Does not address the issue of consent or the need for intervention.
B: Shifts focus from perpetrator to victim, potentially placing blame.
C: Focuses on legal action without addressing the patient's emotional needs.
D: Empowers the patient, emphasizes consent, and prioritizes safety and prevention.
A nurse plans an educational program for staff of a home health agency specializing in care of the elderly. Which topic is the highest priority to include?
- A. Pain assessment techniques for older adults
- B. Psychosocial stimulation for those who live alone
- C. Preparation of psychiatric advance directives in the elderly
- D. Ways to manage disinhibition in elderly persons with dementia
Correct Answer: A
Rationale: The correct answer is A: Pain assessment techniques for older adults. This is the highest priority as pain management is crucial in the care of the elderly to ensure their comfort and well-being. By assessing pain accurately, appropriate interventions can be implemented.
- Choice B (Psychosocial stimulation): While important, it is not as critical as addressing pain, which directly impacts the individual's physical comfort.
- Choice C (Psychiatric advance directives): Important for mental health planning but not as immediately essential as pain assessment in day-to-day care.
- Choice D (Managing disinhibition in dementia): Important but secondary to addressing pain, which has a more immediate impact on the individual's quality of life.
Prioritizing pain assessment ensures holistic care for elderly patients.
Disturbed body image is the nursing diagnosis for a patient with an eating disorder. Which outcome indicator is most applicable to this diagnosis?
- A. Weight, muscle, and fat congruence with height, frame, age, and sex.
- B. Calorie intake within required parameters of treatment plan.
- C. Weight at established normal range for the patient.
- D. None of the above.
Correct Answer: A
Rationale: The correct answer is A because disturbed body image in an eating disorder patient involves a discrepancy between their perceived body image and reality. Monitoring weight, muscle, and fat congruence with height, frame, age, and sex helps assess if the patient's perception aligns with their actual physical state. Choice B focuses solely on calorie intake, which does not directly address body image perception. Choice C only considers weight, neglecting the importance of muscle and fat distribution in body image perception. Choice D is incorrect as option A is the most relevant outcome indicator for disturbed body image in this scenario.
Which environmental factor most hinders mental development?
- A. Lack of sleep
- B. Poor nutrition
- C. Excessive screen time
- D. Noisy surroundings
Correct Answer: B
Rationale: Poor nutrition (B) most hinders mental development by limiting brain growth and function. Sleep (A), screen time (C), and noise (D) impact development, but nutrition is foundational.