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Which of the following is the percentage of pre-school children who are diagnosed with a phonological disorder of unknown origin?
- A. 4%
- B. 5%
- C. 6%
- D. 3%
Correct Answer: D
Rationale: Phonological Disorder: Approximately 3% of pre-school children are diagnosed with this disorder of unknown origin, characterized by failure to use developmentally expected speech sounds.
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A patient was admitted in a semistuporous catatonic state. Family states that the patient has neither left the apartment nor attended to personal hygiene for several weeks. The patient's last 48 hours have been spent lying in bed, mute and motionless. The nursing diagnosis that should be considered the priority is:
- A. self-care deficit.
- B. situational low self-esteem.
- C. disturbed thought processes.
- D. impaired verbal communication.
Correct Answer: A
Rationale: The correct answer is A: self-care deficit. This nursing diagnosis should be considered the priority because the patient is unable to attend to personal hygiene and has been lying in bed motionless and mute for 48 hours, indicating a significant impairment in self-care abilities. This is a critical issue that needs immediate attention to prevent further deterioration in the patient's physical and mental health.
Choice B: situational low self-esteem is not the priority as the patient's current state is more indicative of physical neglect rather than a self-esteem issue.
Choice C: disturbed thought processes may be a contributing factor to the patient's presentation, but the priority at this moment is addressing the self-care deficit to ensure the patient's safety and well-being.
Choice D: impaired verbal communication, while important, is not the priority in this scenario as the patient's inability to communicate verbally is secondary to the urgent need for assistance with self-care.
During an initial patient interview, the psychiatric-mental health nurse begins by asking the patient to describe their:
- A. current situation
- B. feelings about the current situation
- C. personal history
- D. thoughts about the current situation
Correct Answer: A
Rationale: Starting with the current situation provides a concrete entry point to assess the patient's immediate needs and context.
Which of the following is an example of a peri-natal cause of intellectual disability when there is a significant period without oxygen occurring during or immediately after delivery?
- A. Anoxia
- B. Pronoxia
- C. Anaphylaxia
- D. Dysnoxia
Correct Answer: A
Rationale: Anoxia: A peri-natal cause of intellectual disability due to a significant period without oxygen during or after delivery.
A patient tells the nurse, "My doctor prescribed Paxil (paroxetine) for my depression. I assume I'll have side effects like I had when I was taking Tofranil (imipramine)." The nurse's reply should be based on the knowledge that paroxetine is a:
- A. Selective norepinephrine reuptake inhibitor.
- B. Tricyclic antidepressant.
- C. MAO inhibitor.
- D. SSRI
Correct Answer: D
Rationale: The correct answer is D: SSRI. Paroxetine belongs to the class of selective serotonin reuptake inhibitors (SSRIs), which work by primarily increasing the levels of serotonin in the brain. This mechanism differs from tricyclic antidepressants like Tofranil (imipramine) and MAO inhibitors. SSRIs are known for having fewer side effects compared to tricyclic antidepressants and MAO inhibitors. Therefore, the nurse should inform the patient that the side effects experienced with Tofranil are not necessarily indicative of what they will experience with Paxil due to the different drug classes.
A victim of a violent rape was treated in the emergency department. As discharge preparation begins, the victim says softly, "I will never be the same again. I can't face my friends. There is no reason to go on."Â Select the nurse's most appropriate response.
- A. Are you thinking of harming yourself?
- B. It will take time, but you will feel the same.
- C. Your friends will understand when you explain it was not your fault.
- D. You will be able to find meaning in this experience as time goes on.
Correct Answer: A
Rationale: The correct answer is A: "Are you thinking of harming yourself?" This response is the most appropriate because the victim is expressing hopelessness and suicidal ideation, which indicates a need for immediate intervention and assessment for safety. By asking directly about self-harm, the nurse can assess the severity of the situation and take appropriate actions to ensure the victim's safety.
Summary of other choices:
B: This response minimizes the victim's feelings and does not address the seriousness of the situation.
C: This response ignores the victim's emotional distress and does not address the potential for self-harm.
D: This response dismisses the victim's current feelings and does not provide immediate support for the expressed hopelessness.