Nokea
Which of the following is a symptom associated with sensory overload?
- A. Disorientation
- B. Drowsiness
- C. Emotional lability
- D. Depression
Correct Answer: A
Rationale: Disorientation is a common symptom associated with sensory overload. When an individual experiences sensory overload, their brain may become overwhelmed with excessive information, leading to disorientation. This can manifest as an inability to concentrate, racing thoughts, and restless behavior. Sensory overload occurs when a person is unable to either control the amount of environmental stimuli they are exposed to or process the stimuli effectively. Drowsiness, emotional lability, and depression are not typical symptoms of sensory overload. Drowsiness may indicate fatigue or boredom, emotional lability refers to rapid and exaggerated changes in mood, and depression is a mood disorder characterized by persistent feelings of sadness and hopelessness.
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A client decides to have hospice care rather than undergo an extensive surgical procedure. Which ethical principle does the client's behavior illustrate?
- A. Justice
- B. Veracity
- C. Autonomy
- D. Beneficence
Correct Answer: C
Rationale: The correct answer is 'Autonomy.' Autonomy refers to an individual's right to make decisions about their own care. In this scenario, the client is choosing hospice care over surgery, demonstrating their autonomy in making healthcare choices. Justice involves fairness and equality in the distribution of resources and services, which is not the primary ethical principle illustrated in this case. Veracity pertains to truthfulness and honesty, which is not directly related to the client's decision-making process. Beneficence refers to the duty to do good and act in the best interest of the patient, which is not the central ethical principle demonstrated by the client's decision for hospice care.
While explaining an illness to a 10-year-old, what should the nurse keep in mind about cognitive development at this age?
- A. They are able to make simple associations of ideas.
- B. They are able to think logically in organizing facts.
- C. Interpretation of events originates from their own perspective.
- D. Conclusions are based on previous experiences.
Correct Answer: B
Rationale: The correct answer is that 10-year-olds are able to think logically in organizing facts. At this age, children are in the concrete operational stage according to Piaget's theory of cognitive development. In this stage, they can understand and organize information logically and can manipulate objects mentally. Choice A is incorrect because simple associations of ideas are more characteristic of earlier developmental stages. Choice C is incorrect as it refers to egocentrism, which is more typical of the preoperational stage. Choice D is incorrect as basing conclusions on previous experiences is a broader concept that applies across different ages and stages of development, rather than being specific to 10-year-olds in the concrete operational stage.
While planning care for a 2-year-old hospitalized child, which situation would the nurse most likely expect to affect the behavior?
- A. Strange bed and surroundings.
- B. Separation from parents.
- C. Presence of other toddlers.
- D. Unfamiliar toys and games.
Correct Answer: B
Rationale: The correct answer is 'Separation from parents.' Separation anxiety is most evident from 6 months to 30 months of age. It is the greatest stress imposed on a toddler by hospitalization. If separation is avoided, young children have a tremendous capacity to withstand other stress. Choices A, C, and D are incorrect because while strange bed and surroundings, presence of other toddlers, and unfamiliar toys and games may contribute to some level of stress or discomfort, the separation from parents is the primary factor affecting the behavior of a 2-year-old hospitalized child.
The nurse has just admitted a client with severe depression. From which focus should the nurse identify a priority nursing diagnosis?
- A. Nutrition
- B. Elimination
- C. Activity
- D. Safety
Correct Answer: D
Rationale: In caring for a client with severe depression, ensuring safety is a top priority. Suicide prevention measures must be incorporated into the care plan as individuals with depression are at increased risk. While nutrition, elimination, and activity are important aspects of care, safety takes precedence due to the critical need to prevent harm or self-harm in depressed individuals.
A woman who had a mastectomy is scheduled for a mastectomy peer support visit arranged by her primary health care provider. What is the purpose of the referral?
- A. To teach arm exercises
- B. To prevent social isolation
- C. To meet her physical needs
- D. To view her surgical incision
Correct Answer: B
Rationale: The purpose of a mastectomy peer support visit is to prevent social isolation. This visit helps the client maintain her social connections and learn about community resources. Teaching arm exercises and meeting physical needs are tasks for healthcare professionals, not the primary goal of a peer support visit. Viewing the surgical incision is also not the primary purpose of such a visit.