Nokea
Which of these is a sign of delayed mental development in toddlers?
- A. Limited speech
- B. Preference for solo play
- C. Not walking by 12 months
- D. Dislike of loud noises
Correct Answer: A
Rationale: Limited speech (A) by toddler age (e.g., few words by 2 years) may indicate delayed mental development, per milestones. Solo play (B) is normal, walking (C) is physical, and noise dislike (D) is sensory.
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A patient, aged 77 years, has Alzheimer's disease. She goes to day care during the week and is otherwise cared for by her daughter and grandchildren. The nurse at the day care center noticed multiple bruises on the patient's palms, elbows, and buttocks. When the daughter arrived to pick her up, the nurse discussed her observations. The daughter became defensive and said that her mother was very difficult to manage. She stated, "My mother is not my mother anymore. She is confused, and she wanders all night. We have to watch her constantly. Last night I fell asleep, and she fell down the stairs. Sometimes she cannot recognize me and accuses me of trying to poison her. I can't concentrate at work, and it's wrecking the family. Sometimes I just cannot bear it."Â Which nursing diagnosis would be most important to address for this family?
- A. Knowledge deficit pertaining to dementia
- B. Grieving related to mother's deterioration
- C. Risk for injury related to cognitive impairment
- D. Caregiver role strain related to increased care needs
Correct Answer: D
Rationale: The correct nursing diagnosis to address in this scenario is D: Caregiver role strain related to increased care needs. This is the most important as it focuses on the daughter's challenges and emotional burden due to her mother's condition. The daughter's statements reveal feelings of overwhelm, guilt, and exhaustion, which are key indicators of caregiver role strain. By addressing this nursing diagnosis, the healthcare team can provide support and resources to help the daughter cope with the demands of caring for her mother.
Choice A (Knowledge deficit pertaining to dementia) is not the most important in this situation as the daughter's issue is not lack of knowledge but rather emotional stress. Choice B (Grieving related to mother's deterioration) is not the priority as addressing the daughter's emotional strain is more urgent than addressing grief. Choice C (Risk for injury related to cognitive impairment) is also important but not as immediate as addressing the caregiver's emotional well-being.
A 10-year-old boy is diagnosed with gender dysphoria. Which assessment finding would the nurse expect?
- A. Having tea parties with dolls
- B. A compromised sexual response cycle
- C. Identifying with boys who are athletic
- D. Intense urges to watch his parents have sex
Correct Answer: A
Rationale: The correct answer is A because a child with gender dysphoria may display behaviors that align with the gender they identify with, such as engaging in activities typically associated with that gender. Tea parties with dolls may indicate the child's preference for activities stereotypically linked to girls, indicating a mismatch between their assigned gender and gender identity. Choices B, C, and D are incorrect as they do not align with typical assessment findings for gender dysphoria in children. B is more related to sexual dysfunction, C is a common behavior for all children, and D is inappropriate and unrelated to the diagnosis of gender dysphoria.
The family of a patient with schizophrenia who has been stable for a year reports to the community mental health nurse that the patient reports feeling tense and having difficulty concentrating. He sleeps only 3 to 4 hours nightly and has begun to talk about creatures called 'volmers' hiding in the warehouse where he works and undoing his work each night. This information most likely suggests:
- A. medication nonadherence.
- B. a need for psychoeducation.
- C. the chronic nature of his illness.
- D. relapse of his schizophrenia.
Correct Answer: D
Rationale: The correct answer is D: relapse of his schizophrenia. The patient is displaying symptoms such as feeling tense, difficulty concentrating, disturbed sleep, and delusional thoughts about creatures hiding in his workplace. These symptoms indicate a return of psychotic features characteristic of schizophrenia, suggesting a relapse. This is supported by the patient's history of schizophrenia and the sudden onset of symptoms after a period of stability. Medication nonadherence (choice A) could be a possible cause, but the patient's symptoms are more indicative of a relapse. While psychoeducation (choice B) is important, the patient's current symptoms require immediate attention for relapse management. The chronic nature of his illness (choice C) is a general characteristic of schizophrenia and does not explain the current symptoms.
A 14-year-old female comes into clinic for a medical certificate once a week for multiple complaints of chest pain and abdominal pain. The complaints are non-specific, and her physical examination is normal. She is quiet with poor eye contact. She states the pain is worse on school days. Her mother is concerned that her daughter is being bullied but won't talk to her. Her mother is also worried that her complaints represent an undiagnosed medical condition. The next best step in management is:
- A. Referral to tertiary hospital to rule out organic cause
- B. HEADSS or other psychosocial screening
- C. Referral for counselling
- D. Reassurance that nothing is wrong
Correct Answer: B
Rationale: HEADSS screening assesses psychosocial factors (e.g., bullying, stress) that may underlie somatic complaints, making it the best next step before referral or reassurance.
The home care nurse assessed a client with a history of dementia who had a herniorrhaphy at an ambulatory surgical center the previous day. The client lives in a senior retirement community and has no close family. The nurse assesses mild dysphasia. The client cannot remember why he has a bandage. He thinks he is in the army and that it is 1950. Appropriate planning for the client should include:
- A. Arranging an appointment at a geriatric assessment program; OT referral for swallowing therapy; teaching to manage public transportation
- B. Attending English class to improve speech; transferring finances to a conservator; employing an aide to help with medications
- C. Arranging Meals on Wheels, attending speech therapy; relocation to a skilled nursing facility if no improvement in 1 month
- D. Assessing diet and meal preparation; assessing environment for safety problems; referral to a dementia program
Correct Answer: D
Rationale: The correct answer, D, is the most appropriate plan because it addresses the client's current needs and safety concerns. Firstly, assessing diet and meal preparation is important due to the client's dysphasia, which may impact their ability to eat safely. Secondly, assessing the environment for safety problems is crucial as the client has dementia and may be at risk of accidents. Lastly, referral to a dementia program is necessary to provide specialized care and support for the client's condition.
Choices A, B, and C are incorrect because they do not directly address the specific needs of the client in terms of dementia, dysphasia, and safety concerns. They focus on unrelated interventions that are not as critical in this scenario.