Nokea
Which behaviors would indicate the need for further assessment to consider avoidant personality disorder?
- A. Withholding of feelings and low self-esteem
- B. Insistence on others conforming to own methods
- C. Engaging in impulsive acts like unsafe sex
- D. Initial charm dissolving into coldness and blaming others
Correct Answer: A
Rationale: Step 1: Withholding of feelings is a key feature of avoidant personality disorder, indicating difficulty in expressing emotions.
Step 2: Low self-esteem is also characteristic, as individuals with this disorder often feel inadequate and inferior.
Step 3: Insistence on others conforming to own methods (B) is more indicative of narcissistic personality disorder.
Step 4: Engaging in impulsive acts like unsafe sex (C) is more aligned with borderline personality disorder.
Step 5: Initial charm dissolving into coldness and blaming others (D) is a trait of antisocial personality disorder.
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An emergency department nurse prepares to assist with examination of a sexual assault victim. What equipment will be needed to collect and document forensic evidence? Select all that apply.
- A. Body map.
- B. DNA swabs.
- C. Photographs.
- D. Pulse oximeter.
Correct Answer: A
Rationale: The correct answer is A: Body map. In cases of sexual assault, a body map is essential to document and track injuries and evidence. It helps in accurately recording the location and nature of injuries on the victim's body. DNA swabs and photographs are also important for collecting forensic evidence. DNA swabs can help in identifying the perpetrator, while photographs can visually document injuries and evidence. However, a pulse oximeter is not typically needed for collecting forensic evidence in cases of sexual assault. It is used to measure oxygen saturation in the blood and is not directly relevant to documenting forensic evidence in this context.
A patient is referred to the visiting nurse agency due to cognitive impairment. Which functional problems is this patient most likely to exhibit?
- A. Inability to bathe and dress independently.
- B. Wandering in and away from his home.
- C. Lability of moods, from sociable to irritable.
- D. None of the above.
Correct Answer: A
Rationale: The correct answer is A: Inability to bathe and dress independently. Cognitive impairment can impact a person's ability to remember tasks and follow routines, resulting in difficulties with self-care activities like bathing and dressing. This is a common functional problem seen in patients with cognitive impairment.
Choice B (Wandering) is more indicative of behavioral symptoms like agitation and restlessness. Choice C (Mood lability) is related to emotional regulation and not directly related to functional problems caused by cognitive impairment. Choice D (None of the above) is incorrect as cognitive impairment often leads to difficulties with self-care tasks.
A normal person sees flashes of light while falling asleep. These are examples of
- A. Hypnopompic hallucinations
- B. Eidetic imagery
- C. Visual hallucinations
- D. Complex hallucinations
Correct Answer: C
Rationale: Flashes of light while falling asleep are hypnagogic visual hallucinations, a normal phenomenon, though 'visual hallucinations' is the closest match here.
Which statement by a patient with anorexia nervosa indicates a need for further education?
- A. I understand that my weight loss is dangerous, and I want to regain weight.
- B. I feel good about my body and don't need to gain weight.
- C. I am willing to work with my healthcare team to restore my nutrition.
- D. I know I need to eat more to improve my health.
Correct Answer: B
Rationale: The correct answer is B because feeling good about their body and not recognizing the need to gain weight is a common symptom of anorexia nervosa. This statement indicates a lack of insight into the seriousness of their condition and the necessity to restore a healthy weight. The other choices (A, C, D) demonstrate an understanding of the importance of weight gain, collaboration with healthcare professionals, and the need for increased food intake to improve health, indicating a willingness to engage in treatment and recovery.
An individual accompanied by a sibling was brought by ambulance to the emergency room with suspected impaired cognitive function. The patient's aggressive behavior and attempts to get out of bed present a safety issue. The nurse should first consider:
- A. applying four-point restraints.
- B. using a calm tone to orient the patient.
- C. leaving the patient alone with the sibling.
- D. calling for security guards to hold the patient down.
Correct Answer: B
Rationale: The correct answer is B: using a calm tone to orient the patient. This is the most appropriate initial intervention because it aims to address the patient's aggressive behavior by providing reassurance and attempting to reorient them to their surroundings. Using a calm tone can help de-escalate the situation and improve communication with the patient. Applying four-point restraints (choice A) should be avoided as it is a restrictive measure that should only be used as a last resort to ensure patient safety. Leaving the patient alone with the sibling (choice C) may exacerbate the safety issue, as the sibling may not be equipped to manage the situation. Calling for security guards to hold the patient down (choice D) is a forceful approach that should be avoided until all other options have been exhausted.