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What is a key indicator of mental development in preschool children?
- A. Ability to count to 10
- B. Following multi-step instructions
- C. Recognizing colors
- D. Walking independently
Correct Answer: B
Rationale: Following multi-step instructions (B) reflects cognitive processing and memory, key mental development indicators in preschoolers. Counting (A) and colors (C) are simpler skills, while walking (D) is physical, not mental.
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State four (4) negative symptoms of schizophrenia
- A. Apathy
- B. Social withdrawal
- C. Blunted affect
- D. Poverty of speech
Correct Answer: A
Rationale: Negative symptoms involve diminished function, such as lack of emotion, isolation, flat affect, and reduced verbal output.
A history reveals that a patient virtually stopped eating 5 months ago and lost 25% of body weight. The nurse says, "Describe what you think about your present weight and how you look."Â Which response would be most consistent with anorexia nervosa?
- A. "I'm fat and ugly."Â
- B. "What I think about myself is my business."Â
- C. "I'm grossly underweight, but I cover it well."Â
- D. "I'm a few pounds overweight, but I can live with it."Â
Correct Answer: A
Rationale: The correct answer is A because the response indicates a distorted body image, a common characteristic of anorexia nervosa. Anorexia nervosa is characterized by an intense fear of gaining weight and a distorted perception of body image, leading individuals to see themselves as overweight despite being underweight. In this case, the patient's response of "I'm fat and ugly" demonstrates a negative perception of their weight and appearance, which aligns with the distorted body image seen in anorexia nervosa.
Choices B, C, and D are incorrect:
B: "What I think about myself is my business" - This response does not indicate a distorted body image or negative perception of weight and appearance, which are key features of anorexia nervosa.
C: "I'm grossly underweight, but I cover it well" - While this response acknowledges being underweight, it does not reflect the distorted body image commonly seen in anorexia nervosa.
D: "I'm a
A widow, aged 72 years, lives alone and is visited weekly by her son. She takes digoxin, hydrochlorothiazide, and an antihypertensive drug. She also has a prescription for diazepam (Valium) as needed for moderate to severe anxiety. When the son visited today, he found his mother confused and disoriented, with an unsteady gait. The nurse assessed the patient as having several cognitive problems, including memory and attention deficits and fluctuating levels of orientation. The nurse confirms that the patient's symptoms developed:
- A. Over the past few days.
- B. Over the past few weeks.
- C. Over the past few months.
- D. None of the above.
Correct Answer: A
Rationale: The correct answer is A: Over the past few days. The sudden onset of confusion, disorientation, and cognitive deficits in the elderly patient suggests an acute change in her condition. This acute change is more indicative of a recent event or medication-related issue rather than a gradual decline over weeks or months. The sudden onset could be due to factors such as medication interactions, overdose, or underlying medical conditions. It is crucial to investigate recent changes in medications, lab results, or any other potential triggers that might have led to this acute cognitive decline. Choices B, C, and D are incorrect because they imply a gradual decline over weeks, months, or no specific timeframe, which does not align with the sudden onset observed in the patient.
A nurse cares for a rape victim who was given flunitrazepam (Rohypnol) by the assailant. Which intervention has priority? Monitoring for:
- A. Coma
- B. Seizures
- C. Hypotonia
- D. Respiratory depression
Correct Answer: D
Rationale: The correct answer is D: Respiratory depression. Flunitrazepam is a sedative-hypnotic drug that can cause central nervous system depression, leading to respiratory depression, which is life-threatening. Monitoring respiratory status is crucial to prevent respiratory failure.
A: Coma may occur but is a consequence of severe respiratory depression, hence monitoring respiratory status is more critical.
B: Seizures are not a common side effect of flunitrazepam and do not pose immediate life-threatening risks compared to respiratory depression.
C: Hypotonia (muscle weakness) is a potential side effect but does not require immediate intervention like respiratory depression.
In summary, monitoring for respiratory depression is the priority as it can lead to respiratory failure and death, while the other choices are not as immediately life-threatening.
What is an appropriate goal for a nurse when working with a patient who has anorexia nervosa?
- A. The patient will achieve rapid weight gain and improve self-esteem.
- B. The patient will restore nutritional balance through safe weight gain.
- C. The patient will accept their body image without therapeutic intervention.
- D. The patient will maintain a healthy weight without any professional assistance.
Correct Answer: B
Rationale: The correct answer is B because restoring nutritional balance through safe weight gain is a realistic and appropriate goal for a nurse working with a patient with anorexia nervosa. This goal focuses on the patient's physical health and addresses the underlying issue of malnutrition. Rapid weight gain (A) may be dangerous and unsustainable. Accepting body image without intervention (C) ignores the severity of the disorder. Maintaining a healthy weight without professional assistance (D) is unlikely for someone with anorexia nervosa who requires specialized care.