Nokea
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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While planning care for a preschool child who has been physically and sexually abused, the nurse includes play therapy because it assists the child to:
- A. Act out aggression in an acceptable manner
- B. Express feelings that cannot easily be verbalized
- C. Interact with other children in the appropriate age group
- D. Learn adaptive behaviors through acting
Correct Answer: B
Rationale: The correct answer is B: Express feelings that cannot easily be verbalized. Play therapy allows preschool children to express their emotions, trauma, and experiences through play activities, as they may not have the verbal skills to communicate their feelings effectively. This form of therapy helps the child process their emotions and experiences in a safe and non-threatening environment.
Incorrect Choices:
A: Acting out aggression in an acceptable manner is not the primary goal of play therapy for abused children. It is more about emotional expression and healing.
C: Interacting with other children in the appropriate age group is not the focus of play therapy for abused children. The primary goal is to address the trauma and emotional distress.
D: Learning adaptive behaviors through acting is not the main purpose of play therapy for abused children. It is more about emotional healing and expression.
In autistic spectrum disorder when as individual exhibits immediate imitation of words or sounds they have just heard, this is known as:
- A. Echoastic disorder
- B. Phonological inhibition
- C. Echolalia
- D. Grapheme dysfunction
Correct Answer: C
Rationale: Echolalia: The immediate imitation of words or sounds heard, a common feature in autistic spectrum disorder.
Which of the following is a priority for a nurse caring for a patient with anorexia nervosa during the refeeding phase?
- A. Providing a high-calorie diet immediately to speed up weight gain.
- B. Monitoring the patient closely for signs of refeeding syndrome.
- C. Promoting the patient's independence in meal choices.
- D. Encouraging exercise to improve physical health.
Correct Answer: B
Rationale: The correct answer is B: Monitoring the patient closely for signs of refeeding syndrome. Refeeding syndrome is a potentially life-threatening condition that can occur when a malnourished individual is fed too quickly. Monitoring for signs such as electrolyte imbalances, fluid shifts, and organ dysfunction is crucial to prevent complications. Providing a high-calorie diet immediately (A) can exacerbate refeeding syndrome. Promoting independence in meal choices (C) may not be appropriate if the patient needs close monitoring. Encouraging exercise (D) can be harmful during the refeeding phase as the body needs time to recover and regain strength.
Which assessment finding is most associated with bulimia nervosa?
- A. Prominent parotid glands
- B. Peripheral edema
- C. Thin, brittle hair
- D. Amenorrhea
Correct Answer: A
Rationale: The correct answer is A: Prominent parotid glands. This is associated with bulimia nervosa due to repeated vomiting, which can lead to enlargement of the parotid glands. This is known as parotid gland hypertrophy. The other choices (B: Peripheral edema, C: Thin, brittle hair, D: Amenorrhea) are more commonly associated with anorexia nervosa rather than bulimia nervosa. Edema is a sign of malnutrition in anorexia, while thin, brittle hair and amenorrhea are also common in anorexia due to severe weight loss and hormonal disturbances.
The priority nursing focus for the period immediately after electroconvulsive therapy treatment should be on:
- A. Monitoring for the return of the capacity for full range of motion.
- B. Assessing the degree of accumulating memory impairment.
- C. Making positive comments while the patient is more receptive.
- D. Assessing the level of consciousness and normal body functions.
Correct Answer: D
Rationale: The correct answer is D: Assessing the level of consciousness and normal body functions. After electroconvulsive therapy (ECT), it is crucial to monitor the patient's level of consciousness and ensure all body functions are normal to detect any potential complications immediately. This includes assessing vital signs, neurological status, respiratory function, and cardiovascular stability. Monitoring for the return of full range of motion (A) is not a priority immediately post-ECT. Assessing memory impairment (B) may be important but is not the immediate priority. Making positive comments (C) is helpful for emotional support but does not address the critical need to assess physical status.