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Which older adult patient’s medical conditions support the hypothesis upon which the immunologic theory of aging is based?
- A. Has, at age 64, been diagnosed with type 2 diabete
- B. Has been treated for multiple sclerosis since age 30.
- C. Is managing a 36-year history of chronic Graves’ disease.
- D. Has begun to experience symptoms of rheumatoid arthritis.
Correct Answer: B, C
Rationale: he immunologic theory of aging suggests that aging is associated with increased autoimmunity. Conditions like multiple sclerosis, rheumatoid arthritis, and Graves’ disease reflect immune dysfunction.
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Which nursing diagnosis is appropriate for a patient who insists on being called "Your Highness" and demonstrates loosely associated thoughts?
- A. Risk for violence
- B. Defensive coping
- C. Impaired memory
- D. Disturbed thought processes
Correct Answer: D
Rationale: nsisting on being called "Your Highness" and demonstrating loose associations suggests a disturbance in thought processing typical of schizophrenia.
An advance directive gives legally binding direction for health care interventions when a patient:
- A. Has a new diagnosis of cancer.
- B. Is diagnosed with Parkinson's disease
- C. Diagnosed with amyotrophic lateral sclerosis is unable to speak.
- D. Is unable to make decisions for self because of illness.
Correct Answer: D
Rationale: An advance directive is used when a patient is unable to make their own healthcare decisions, typically due to a serious illness or injury. This legal document outlines the patient’s wishes for treatment and care.
A young woman had just learned of the accidental death of her husband. She begins to cry and states, “It’s not fair! How could he do this to me?” This remark is assessed as:
- A. An explosive episode
- B. An expression of anger
- C. Fear of making decisions alone
- D. A sign of despair.
Correct Answer: B
Rationale: The woman's statement, "It's not fair! How could he do this to me?" expresses a sense of anger and injustice over her husband's accidental death. She is questioning why this has happened to her, which suggests feelings of anger and frustration. This expression is not necessarily a plea for help or a manifestation of fear of making decisions alone, but it is a clear display of anger and a sense of unfairness in the situation.
When leading a therapeutic group, the nurse demonstrates an understanding of the need to act as the group’s executive when:
- A. Restating rules when a new member joins
- B. Being available to orient the new members
- C. Helping a member defuse the anger they are experiencing
- D. Offering personal opinions on group topics
Correct Answer: A
Rationale: When leading a therapeutic group, the nurse's role as the group's executive involves setting and maintaining boundaries, ensuring adherence to the group's rules, and creating a safe and structured environment for all members. Restating rules when a new member joins helps to establish expectations and maintain consistency within the group. It allows the nurse to assert authority and guide the group in a direction that is conducive to therapeutic progress. By upholding the rules and boundaries of the group, the nurse helps to create a sense of safety and trust among the members, allowing for open and productive communication and shared growth.
Which response is appropriate when a patient’s mother expresses guilt over causing my child to be schizophrenic?
- A. I can see how you would be upset over this turn of events
- B. New findings suggest this disorder is biological in nature.
- C. Don’t be so hard on yourself; your daughter needs you to be strong
- D. It’s difficult to see what produces stress for the child at the time it’s occurring.
Correct Answer: B
Rationale: Schizophrenia is primarily linked to biological factors, including genetic predispositions, neurochemical imbalances, and brain structure abnormalities. This response helps dispel guilt and provides reassurance to the mother.