Nokea
Which of the following are behaviours that may be associated with adolescent depression?
- A. School refusal
- B. Social withdrawal
- C. Reduced self-care
- D. Maladaptive coping behaviours
Correct Answer: A
Rationale: School refusal is a well-documented behavior associated with adolescent depression; the question implies a single correct answer, though B-D are also relevant.
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During morning care, the nursing assistant asks a patient with dementia, 'How was your night?' The patient replies, 'It was lovely. My husband and I went out to dinner and to a movie.' The nurse who overhears this should make the assessment that the patient is:
- A. Demonstrating a sense of humor.
- B. Using confabulation.
- C. Perseverating.
- D. None of the above.
Correct Answer: B
Rationale: The correct answer is B: Using confabulation. Confabulation is when a person with dementia unknowingly creates fictitious memories to fill in gaps in their memory. In this scenario, the patient's response of going out to dinner and a movie with their husband is not based in reality, indicating confabulation. A: Demonstrating a sense of humor is incorrect because the patient is not intentionally being humorous. C: Perseverating is incorrect as it refers to repeating the same words or phrases, which is not evident in the patient's response. D: None of the above is incorrect as the patient's response aligns with confabulation.
A new nurse asks the experienced nurse who is caring for a battered woman client, 'Why did you ask about culture when it was obvious you needed to focus on the battering?' The experienced nurse should respond:
- A. It's just a habit I got into a while ago.'
- B. It helps me focus on whether to do a complete physical assessment.'
- C. Culture is a determinant of how women interpret and respond to violence.'
- D. If I know more about her I can refer her to a shelter that caters to her ethnic group.'
Correct Answer: C
Rationale: Rationale:
- Choice C is correct because culture influences how individuals perceive and respond to violence, impacting their help-seeking behaviors and coping mechanisms.
- Understanding the client's cultural background is crucial for providing appropriate care and support.
- Choices A, B, and D are incorrect as they do not address the importance of considering culture in understanding and addressing domestic violence in this context.
Parkinson's disease results from the death of neurons that produce
- A. serotonin
- B. acetylcholine
- C. dopamine
- D. norepinephrine
Correct Answer: C
Rationale: Parkinson's involves dopamine neuron loss, leading to motor and cognitive symptoms.
The caregiver for a client with moderate to severe dementia tells the nurse, 'I'm exhausted. He wanders at night instead of sleeping, so I get no rest. I'm afraid to leave him during the day, so I have to take him to the grocery store and to the laundromat. When I'm busy there, he often wanders off. Still, I have to do it all.' The nurse recognizes the need to provide teaching for this caregiver. An appropriate outcome is that the caregiver will:
- A. Develop strategies to ensure the client's safety.
- B. Seek respite care to get a break.
- C. Join a support group for caregivers.
- D. None of the above.
Correct Answer: A
Rationale: The correct answer is A: Develop strategies to ensure the client's safety. This is the most appropriate outcome as it directly addresses the caregiver's concerns of the client wandering and ensures their safety. By developing strategies such as installing door alarms, creating a safe sleeping environment, and establishing a routine, the caregiver can mitigate the risks associated with wandering behavior.
Summary:
- B: Seek respite care to get a break: While respite care is important for caregiver well-being, it does not directly address the safety concerns of the client wandering.
- C: Join a support group for caregivers: While support groups can be beneficial for emotional support, they may not provide immediate solutions to ensure the client's safety.
A patient with acute mania dances atop a pool table, waves a cue in one hand, and says, "I'll throw the pool balls if anyone comes near me." The nurse's first intervention is to:
- A. Tell the patient
- B. ""We are taking you to seclusion.""
- C. Remove the patient from the pool table.
- D. Clear the room of all other patients.
Correct Answer: B
Rationale: The correct answer is B because taking the patient to seclusion ensures safety for both the patient and others. This intervention controls the immediate risk of harm from the patient's unpredictable behavior. Telling the patient (choice A) may escalate the situation. Removing the patient from the pool table (choice C) may not address the underlying threat. Clearing the room of all other patients (choice D) is not the priority; ensuring immediate safety is paramount in this scenario.