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Which statement by a patient with borderline personality disorder best indicates the treatment plan is helping?
- A. I think you are the best nurse on the unit.'
- B. I hate my doctor. He never gives me what I ask for.'
- C. I feel empty and want to cut myself, so I called you.'
- D. I'm never going to get high on drugs again.'
Correct Answer: C
Rationale: The correct answer is C. This statement indicates progress because the patient is demonstrating insight into their emotions, seeking help, and utilizing a coping strategy by reaching out for support instead of engaging in self-harm. Choice A does not provide information about progress in treatment. Choice B reflects a negative attitude towards the doctor. Choice D does not offer any insight into the patient's emotional state or progress in managing their behaviors.
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The therapeutic approach in the care of an autistic child include the following EXCEPT:
- A. Engage in diversionary activities when acting out
- B. Provide an atmosphere of acceptance
- C. Provide safety measures
- D. Rearrange the environment to activate the child
Correct Answer: D
Rationale: Rearranging the environment to activate the child may overstimulate an autistic child, who typically benefits from consistency and calm settings.
Which symptom of Alzheimer's disease is associated with disorientation to time and place?
- A. Forgetting in what order to put clothes on
- B. Forgetting simple words
- C. Forgetting where he or she lives
- D. Becoming suspicious of others
Correct Answer: C
Rationale: The correct answer is C: Forgetting where he or she lives. In Alzheimer's disease, disorientation to time and place is a common symptom due to memory loss and cognitive decline. Forgetting where one lives directly relates to disorientation, as the individual may not recognize their home or surroundings. Choice A is related to sequencing and executive function, not specific to time and place. Choice B is more associated with language and communication difficulties. Choice D relates to paranoia or mistrust, not specifically related to disorientation to time and place. In summary, the correct answer directly reflects the symptom of disorientation in Alzheimer's disease, while the other choices are related to different cognitive functions.
Disturbed body image is the nursing diagnosis for a patient with an eating disorder. Which outcome indicator is most applicable to this diagnosis?
- A. Weight, muscle, and fat congruence with height, frame, age, and sex.
- B. Calorie intake within required parameters of treatment plan.
- C. Weight at established normal range for the patient.
- D. None of the above.
Correct Answer: A
Rationale: The correct answer is A because disturbed body image in an eating disorder patient involves a discrepancy between their perceived body image and reality. Monitoring weight, muscle, and fat congruence with height, frame, age, and sex helps assess if the patient's perception aligns with their actual physical state. Choice B focuses solely on calorie intake, which does not directly address body image perception. Choice C only considers weight, neglecting the importance of muscle and fat distribution in body image perception. Choice D is incorrect as option A is the most relevant outcome indicator for disturbed body image in this scenario.
Which situation is consensual sex rather than rape?
- A. A husband forces vaginal sex when he comes home intoxicated from a party. The wife objects.
- B. A woman's lover pleads with her to have oral sex. She gives in but then regrets the decision.
- C. A person is beaten, robbed, and forcibly subjected to anal penetration by an assailant.
- D. A dentist gives anesthesia for a procedure and then has intercourse with the unconscious patient.
Correct Answer: B
Rationale: The correct answer is B because, although the woman initially gave in to her lover's plea for oral sex, she later regretted the decision. Consent must be freely given without coercion or manipulation. In this scenario, the woman's regret indicates that her initial agreement was not genuine consent. Choice A involves force and lack of consent. Choice C depicts a violent and non-consensual act. Choice D involves taking advantage of a vulnerable and unconscious individual, which is also non-consensual.
In DSM-IV-TR intellectual disabilities are divided into a number of degrees of severity, depending primarily on the range of IQ score provided by the sufferer. One of these is Profound Mental Retardation, represented by an IQ score below:
- A. 20-25
- B. 25-30
- C. 15-20
- D. 15-Oct
Correct Answer: A
Rationale: Profound Mental Retardation: Defined by DSM-IV-TR as an IQ score below 20-25.