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Which of the following statements is true about the differences in mental health problems between children and adults?
- A. Children are affected by the same stressors as adults, but to different degrees and with different manifestations
- B. Childrens mental health disorders are generally much less severe and resolve more quickly than do those of adults
- C. Childrens mental health problems are different from those of adults because their brains are wired differently
- D. Children have better means of working off stresses than do adults
Correct Answer: A
Rationale: Mental health disorders in children have many similarities and differences from the same disorders in adults. The other responses are not correct.
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The nurse is to perform a complete assessment of a client in her home, using the Mini-Mental State Examination as one component. When the nurse arrives, the client is seated at the table with her husband, the TV is on, and several grandchildren are visiting. The client's husband says, 'Let's get on with this business.' The client is quiet, but her hands are gripped tightly, and she is staring at the ceiling. The best action for the nurse to take would be to:
- A. Explain to the husband that accurate data will be sought, and ask him to stay with the grandchildren in another room
- B. Explain the importance of the testing process and make an appointment for another day when the environment can be better controlled
- C. Not perform the test during the assessment (because it will not be valid) and rely on observations and reports from the family
- D. Ask the husband to make an appointment to bring his wife to the clinic for testing
Correct Answer: B
Rationale: The correct answer is B because conducting a Mini-Mental State Examination (MMSE) in a distracting environment with the client exhibiting signs of distress would likely yield inaccurate results. By explaining the importance of the testing process and rescheduling for a quieter day, the nurse ensures a more accurate assessment. This allows for a controlled environment conducive to obtaining reliable data.
Choice A is incorrect because simply moving the husband and grandchildren to another room may not eliminate distractions or address the client's distress, potentially still impacting the accuracy of the assessment.
Choice C is incorrect as relying solely on observations and reports from the family may not provide a comprehensive assessment of the client's cognitive function, as the MMSE is a standardized tool designed for objective evaluation.
Choice D is incorrect as it does not address the immediate issue of conducting the assessment in a more suitable environment and may disrupt the client's routine by requiring a clinic visit.
A nurse cares for a rape victim who was given flunitrazepam (Rohypnol) by the assailant. Which intervention has priority? Monitoring for:
- A. Coma
- B. Seizures
- C. Hypotonia
- D. Respiratory depression
Correct Answer: D
Rationale: The correct answer is D: Respiratory depression. Flunitrazepam is a sedative-hypnotic drug that can cause central nervous system depression, leading to respiratory depression, which is life-threatening. Monitoring respiratory status is crucial to prevent respiratory failure.
A: Coma may occur but is a consequence of severe respiratory depression, hence monitoring respiratory status is more critical.
B: Seizures are not a common side effect of flunitrazepam and do not pose immediate life-threatening risks compared to respiratory depression.
C: Hypotonia (muscle weakness) is a potential side effect but does not require immediate intervention like respiratory depression.
In summary, monitoring for respiratory depression is the priority as it can lead to respiratory failure and death, while the other choices are not as immediately life-threatening.
Which statement by a patient with bulimia nervosa indicates a need for further education?
- A. I understand that purging can damage my body in the long term.
- B. I feel better after purging, but I know it's not a healthy behavior.
- C. I believe I can control my eating and purging behaviors without help.
- D. I know I need therapy to address my unhealthy relationship with food.
Correct Answer: C
Rationale: Rationale:
Choice C indicates a need for further education because it suggests the patient believes they can manage bulimia without help. Patients with bulimia often require professional intervention for successful treatment. Choices A, B, and D acknowledge the need for therapy, understanding of long-term consequences, and recognition of unhealthy behaviors, respectively.
A nurse is providing care for a patient diagnosed with bulimia nervosa. What is a priority nursing intervention?
- A. Encourage regular exercise to promote weight loss.
- B. Provide a calm, structured environment with consistent mealtimes.
- C. Focus on weight loss as the most important goal.
- D. Offer the patient a high-protein diet to restore health.
Correct Answer: B
Rationale: The correct answer is B: Provide a calm, structured environment with consistent mealtimes. This is the priority intervention because individuals with bulimia nervosa benefit from a stable and supportive environment to establish regular eating patterns and reduce anxiety around mealtimes. This intervention helps promote a sense of safety and predictability, which are crucial for managing the eating disorder. Encouraging regular exercise (Choice A) may exacerbate compulsive behaviors related to bulimia. Weight loss (Choice C) should not be the focus as it can worsen the patient's condition. Offering a high-protein diet (Choice D) may not address the underlying psychological issues associated with bulimia.
Which of the following are considered red flags for a communication disorder?
- A. Speech onset at 24 months, lack of pointing to indicate needs, and poor eye contact
- B. Short attention, odd intonation of speech, and poor pretend play
- C. Lack of pointing to show interests or needs, poor eye contact, and reduced joint attention
- D. Weak vocabulary, reduced joint attention, and poor interaction with peers
Correct Answer: C
Rationale: Red flags for communication disorders include lack of pointing to show interests/needs, poor eye contact, and reduced joint attention, as these indicate deficits in social communication, per developmental guidelines.