Nokea
Which of the following can potentially be diagnostic at the clinic?
- A. The Ages & Stages questionnaire
- B. The Vanderbilt Rating Scale
- C. The MCHAT R/F
- D. The Goodenough Draw a Man test
Correct Answer: C
Rationale: The MCHAT-R/F (Modified Checklist for Autism in Toddlers, Revised with Follow-up) is a validated diagnostic screening tool for autism that can be used in a clinic setting, unlike the others which are more general developmental or cognitive assessments.
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A patient was abducted and raped at gunpoint by an unknown assailant. Which nursing interventions are appropriate while caring for the patient in the emergency department? Select all that apply.
- A. Allow the patient to talk at a comfortable pace.
- B. Place the patient in a private room with a caregiver.
- C. Pose questions in nonjudgmental, empathetic ways.
- D. None of the above.
Correct Answer: A
Rationale: The correct answer is A: Allow the patient to talk at a comfortable pace. This intervention is appropriate because it promotes the patient's autonomy and empowerment in sharing their experience, which can be therapeutic. It also helps establish trust and rapport, facilitating effective communication and assessment.
Incorrect choices:
B: Placing the patient in a private room with a caregiver can be important for privacy and support but may not be the immediate priority.
C: Posing questions in nonjudgmental, empathetic ways is crucial but may not be as important as allowing the patient to talk at their own pace initially.
D: None of the above is incorrect as allowing the patient to talk is a crucial step in providing appropriate care for a patient who has experienced trauma.
A client with catatonic schizophrenia has been posturing, standing with his left arm upraised and his right foot off the floor. For the most part, he ignores attempts at nursing intervention but will occasionally walk, sit, or lie down for a few minutes. The client eats standing up if the nurse brings a tray to the room. The priority nursing order would be to:
- A. Insist that client sit or lie down for 30 minutes hourly
- B. Assess for lower extremity edema bid
- C. Provide high-calorie drinks hourly
- D. Take client to activities therapy once daily
Correct Answer: B
Rationale: The correct answer is B: Assess for lower extremity edema bid. It is important to assess for lower extremity edema in this client with catatonic schizophrenia as posturing in a standing position for prolonged periods can lead to decreased circulation and potential development of edema. This assessment is crucial to monitor the client's physical health and prevent complications such as deep vein thrombosis.
Choice A is incorrect as insisting the client sit or lie down for 30 minutes hourly may not address the underlying issue of potential lower extremity edema and could potentially worsen the client's condition by causing distress.
Choice C is incorrect as providing high-calorie drinks hourly does not address the immediate physical health concern of lower extremity edema and may not be appropriate without a comprehensive assessment of the client's nutritional needs.
Choice D is incorrect as taking the client to activities therapy once daily does not address the immediate need for assessing lower extremity edema and may not be suitable if the client's physical health
When a psychiatric technician questions the nurse about comorbidity of eating disorders, which Axis I disorder would the nurse say is most commonly seen in clients with bulimia and anorexia nervosa?
- A. Anxiety disorders.
- B. Depressive disorders.
- C. Dissociative disorders.
- D. Somatoform disorders.
Correct Answer: B
Rationale: The correct answer is B: Depressive disorders. Depression is commonly seen in clients with bulimia and anorexia nervosa due to the psychological and emotional struggles associated with these eating disorders. Individuals may experience feelings of worthlessness, hopelessness, and sadness, contributing to depressive symptoms. This comorbidity is well-documented in clinical research. Anxiety disorders (Choice A), dissociative disorders (Choice C), and somatoform disorders (Choice D) are less commonly associated with eating disorders compared to depressive disorders, making them incorrect choices in this context.
A nurse is working with a patient with bulimia nervosa. Which outcome would indicate successful intervention?
- A. The patient eats three full meals daily without purging.
- B. The patient agrees to begin psychotherapy without resistance.
- C. The patient loses 5% of their body weight over 3 months.
- D. The patient expresses improved body image but still purges occasionally.
Correct Answer: A
Rationale: The correct answer is A because it indicates successful intervention in bulimia nervosa by demonstrating healthy eating behavior without purging. This outcome reflects improved control over binge-purge cycles and supports physical health. Choices B and D show progress but do not directly address the core issue of purging behavior. Choice C, losing weight, can be a misleading indicator and may not necessarily reflect improved psychological and behavioral outcomes associated with recovery from bulimia nervosa.
A 79-year-old white male tells a nurse, 'I have felt very sad lately. I do not have much to live for. My family and friends are all dead, and my own health is failing.' The nurse should analyze this comment as
- A. normal pessimism of the elderly.
- B. evidence of risks for suicide.
- C. a call for sympathy.
- D. normal grieving.
Correct Answer: B
Rationale: The correct answer is B: evidence of risks for suicide. The elderly man's statement indicates feelings of hopelessness, loneliness, and lack of purpose, which are common risk factors for suicide in older adults. The nurse should assess further for suicidal ideation and intervene accordingly.
Choice A is incorrect because the statement goes beyond normal pessimism by expressing thoughts of not having much to live for. Choice C is incorrect as the statement is more indicative of distress rather than a mere call for sympathy. Choice D is incorrect as normal grieving typically involves processing emotions related to a specific loss, whereas the man's statement reflects a broader sense of despair.