Nokea
Which person has the greatest potential for developing dysfunctional grief?
- A. A teen who has always been one of the popular kids
- B. A widow who regularly states, I really loved my deceased wife
- C. A woman whose husband died as a result of a sudden, traumatic injury
- D. An adult who has dealt with the loss of several family members over the years
Correct Answer: C
Rationale: The correct answer is C because sudden, traumatic deaths can lead to complicated grief reactions. This type of loss can disrupt the individual's ability to process and accept the death, resulting in prolonged and intense emotional distress. The other choices, A, B, and D, do not inherently indicate a higher potential for dysfunctional grief as they do not involve the same level of suddenness or trauma. Teen popularity, expressing love for a deceased spouse, and experiencing multiple losses over time are common situations that may not necessarily lead to dysfunctional grief if appropriate support and coping mechanisms are in place.
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When making a distinction as to whether an elderly patient has confusion related to delirium or another problem, what information would be of particular value?
- A. Evidence of spasticity or flaccidity
- B. The patient’s level of motor activity
- C. Medications the patient has recently taken
- D. Level of preoccupation with somatic symptoms
Correct Answer: C
Rationale: The correct answer is C: Medications the patient has recently taken. This information is crucial because certain medications can cause symptoms of delirium or exacerbate confusion in elderly patients. By reviewing the patient's recent medications, healthcare providers can identify potential drug-induced causes of confusion and adjust the treatment accordingly.
Choice A (Evidence of spasticity or flaccidity) is incorrect because these symptoms are more related to neurological conditions such as stroke or spinal cord injury, not specifically delirium.
Choice B (The patient’s level of motor activity) is not as relevant in distinguishing delirium from other problems as medication history, as motor activity can be influenced by various factors.
Choice D (Level of preoccupation with somatic symptoms) is also less relevant compared to medication history in differentiating delirium, as somatic symptoms may not always directly indicate the underlying cause of confusion in elderly patients.
A patient states, "I’m not worth anything. I have negative thoughts about myself. I feel anxious and shaky all the time. Sometimes I feel so sad that I want to go to sleep and never wake up." Which nursing intervention should have the highest priority?
- A. Self-esteem-building activities.
- B. Anxiety self-control measures.
- C. Sleep enhancement activities.
- D. Suicide precautions.
Correct Answer: D
Rationale: The correct answer is D: Suicide precautions. The patient's statement indicates they are experiencing severe depression and suicidal ideation. Suicide precautions should be the highest priority to ensure the patient's safety. This includes removing any potential means of self-harm, constant monitoring, and close supervision. Self-esteem-building activities (A) may be helpful in the long term but are not the immediate priority. Anxiety self-control measures (B) are important but addressing suicidal ideation takes precedence. Sleep enhancement activities (C) are also important but not the highest priority when dealing with suicidal thoughts.
Which nursing intervention supports the principles on which the cross-links theory of aging is based?
- A. Applying an elastin-sustaining moisturizer to an adult patient’s skin
- B. Assessing a patient’s family history for genetic diseases and disorders
- C. Questioning a patient about long-term exposure to environmental toxins
- D. Assisting an adult patient in selecting foods high in vitamins A, C, and E
Correct Answer: D
Rationale: The correct answer is D because selecting foods high in vitamins A, C, and E supports the principles of the cross-links theory of aging, which focuses on the accumulation of damage from oxidative stress. Vitamins A, C, and E are antioxidants that help combat oxidative stress and reduce the formation of cross-links in tissues. This intervention can potentially slow down the aging process by reducing cellular damage.
Choice A is incorrect because applying an elastin-sustaining moisturizer does not directly address the oxidative stress aspect of the cross-links theory of aging.
Choice B is incorrect as assessing family history for genetic diseases does not specifically target the mechanisms involved in the cross-links theory of aging.
Choice C is incorrect because questioning about exposure to environmental toxins may be important for overall health but is not directly related to the principles of the cross-links theory of aging.
The nurse is assessing a child with autism. Which of the following behaviors would the nurse expect to observe?
- A. Referring to their imaginary friend, Skipper
- B. Asking to telephone my friends on the weekends
- C. Repeating, milk, milk, milk, milk until given a drink.
- D. Is insistent that a dim light be left on in the bedroom at night
Correct Answer: C
Rationale: The correct answer is C: Repeating, milk, milk, milk, milk until given a drink. This behavior is a characteristic of children with autism, known as echolalia. Echolalia is the repetition of words or phrases spoken by others, often used by individuals with autism to communicate or self-soothe. This behavior is a common feature of autism spectrum disorder and is indicative of language difficulties and communication challenges.
Choices A, B, and D are incorrect because they do not specifically relate to behaviors typically observed in children with autism. Referring to an imaginary friend (A) is not exclusive to autism, asking to telephone friends on weekends (B) is a social behavior that can be seen in children without autism, and insisting on a dim light in the bedroom (D) is a preference that does not directly relate to the core characteristics of autism.
The wife of a patient diagnosed with paranoid schizophrenia asks: “I’ve been told that my husband’s illness is probably related to imbalanced brain chemicals. Can you be more specific?”
- A. Breakdown of dopamine produces LSD, which in large amounts produces psychosis
- B. Decreased amounts of the brain chemical dopamine explain the presence of delusions and hallucinations.
- C. An increase in the brain chemical dopamine explains the presence of delusions and hallucinations.
- D. An increase in the brain chemical dopamine explains the presence of lack of motivation and disordered affect
Correct Answer: C
Rationale: The correct answer is C: An increase in the brain chemical dopamine explains the presence of delusions and hallucinations. In paranoid schizophrenia, there is an overactivity of dopamine receptors in the brain, leading to an excess of dopamine. This excess dopamine is associated with symptoms like delusions and hallucinations. Therefore, an increase in dopamine levels is directly linked to these specific symptoms in individuals with paranoid schizophrenia.
Explanation for why the other choices are incorrect:
A: Breakdown of dopamine producing LSD does not directly relate to the symptoms of paranoid schizophrenia.
B: Decreased amounts of dopamine do not explain the presence of delusions and hallucinations in paranoid schizophrenia; it is the increase in dopamine that is associated with these symptoms.
D: An increase in dopamine is more closely related to delusions and hallucinations rather than lack of motivation and disordered affect in paranoid schizophrenia.