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Which of the following meets the DSM-IV-TR criteria for moderate mental retardation?
- A. Requires constant one-on-one supervision and total physical care
- B. Advanced as far as the second grade and provides her own personal care with supervision
- C. Attends the local community college for developmental English and math courses
- D. Advanced as far as the sixth grade and works at a warehouse every day and supports himself.
Correct Answer: D
Rationale: The correct answer is D because the DSM-IV-TR criteria for moderate mental retardation includes an IQ range of 35-49, which typically corresponds to functioning at around the level of a 6 to 9-year-old. Choice D best fits this criteria as the individual has advanced to the sixth grade level academically, indicating a level of functioning consistent with moderate mental retardation. Choices A, B, and C do not meet the criteria as they suggest a higher level of functioning and independence than what is typically associated with moderate mental retardation.
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A 70-year-old male has the nursing diagnosis of situational low self-esteem related to forced retirement. Using Maslow’s hierarchy, the nurse is confident the patient is meeting self-worth outcomes when the patient:
- A. Moves to a secure apartment building
- B. Exercises regularly with friends at the gym
- C. Attends his grandchildren’s school functions
- D. Volunteers at the local homeless shelter weekly
Correct Answer: D
Rationale: The correct answer is D because volunteering at the local homeless shelter fulfills the self-actualization need in Maslow's hierarchy. By helping others and contributing to the community, the patient gains a sense of purpose and fulfillment, boosting self-esteem.
A: Moving to a secure apartment building addresses safety needs, not self-esteem.
B: Exercising with friends promotes social belonging but does not directly address self-esteem.
C: Attending grandchildren's functions fosters social connections, but it may not directly impact self-esteem like volunteering does.
Which intervention best reflects the nursing role regarding effective implementation of behavioral therapy goals?
- A. Administering the prescribed medications accurately
- B. Interacting effectively with members of the health care team
- C. Being aware of all the patient related therapeutic modalities
- D. Evaluating patient behaviors to reward economic tokens appropriately
Correct Answer: D
Rationale: The correct answer is D because evaluating patient behaviors to reward economic tokens appropriately is a key aspect of behavioral therapy. By assessing and reinforcing positive behaviors with rewards, nurses can encourage patients to continue working towards their therapy goals. Administering medications accurately (choice A) is important but not directly related to behavioral therapy goals. Interacting effectively with the health care team (choice B) is important for overall patient care but does not specifically address behavioral therapy. Being aware of therapeutic modalities (choice C) is important but does not directly contribute to implementing behavioral therapy goals like choice D does.
Which statement made by a patient just prior to being transported for a scheduled ECT treatment would result in cancellation of the treatment?
- A. “Will I remember having this treatment?”
- B. “Did eating some crackers cause any problems?”
- C. "Is this going to help me feel better soon?"
- D. "I feel like I need to ask more questions about the procedure."
Correct Answer: A
Rationale: The correct answer is A because asking about memory loss indicates a lack of informed consent and understanding of ECT procedure. Memory loss is a common side effect of ECT, and a patient should be well-informed about it before treatment. Choices B, C, and D do not raise concerns about the patient's understanding or readiness for ECT, making them incorrect. Choice B asks about dietary concerns, which do not directly impact the treatment. Choice C shows the patient's hope for improvement, which is a positive attitude. Choice D indicates the patient's desire for more information, which is a sign of engagement in their care.
How can the nurse encourage an extremely shy patient to participate therapeutically in a dance activity group?
- A. Offer to dance with the patient.
- B. Ask the patient if this is the first dance he has attended.
- C. Sit with the patient away from the group.
- D. Encourage another patient to ask him to dance.
Correct Answer: A
Rationale: The correct answer is A because offering to dance with the patient shows support, builds trust, and models behavior. This approach can help the shy patient feel more comfortable and encouraged to participate. Choice B focuses on the patient's past experience, which may not directly address the current issue. Choice C isolates the patient, potentially increasing feelings of shyness. Choice D involves a third party, which may not be as effective in building a direct connection with the shy patient. Overall, option A is the most effective in directly engaging and encouraging the shy patient to participate therapeutically in the dance activity group.
Which statement best explains how a mother of several children should prepare to help them cope with the loss of a dear aunt?
- A. Each child will grieve in a unique way and on their own timetable
- B. Children are resilient and simply need love as they grieve.
- C. People regardless of age or gender experience stages of grief.
- D. Extreme reactions are more commonly observed in the young griever
Correct Answer: A
Rationale: The correct answer is A because each child will indeed grieve in a unique way and on their own timetable. This approach recognizes the individuality of each child's emotions and coping mechanisms. By understanding and respecting their differences, the mother can provide tailored support and comfort. Option B oversimplifies the grieving process and ignores the complexity of individual responses. Option C generalizes the stages of grief for all people and does not account for variations in how children may process loss. Option D incorrectly suggests that extreme reactions are more common in young children, which is not necessarily true as grief responses can vary widely among children.