Nursing Elites

1. During a clinic visit, the mother of a 7-year-old reports to the nurse that her child is often awake until midnight playing and is then very difficult to awaken in the morning for school. Which assessment data should the nurse obtain in response to the mother's report?

• A. The occurrence of any episodes of sleep apnea
• B. The child's blood pressure, pulse, and respirations
• C. Length of rapid eye movement (REM) sleep that the child is experiencing
• D. Description of the family's home environment

Correct answer: D

Rationale: When a school-age child has difficulty going to sleep and waking up in the morning, it is important to assess the family's home environment. This includes factors such as bedtime rituals, noise levels, lighting, use of electronic devices, and overall sleep hygiene practices. Understanding the home environment can help identify issues that may be contributing to the child's sleep problems and guide the development of a plan to promote better sleep habits. Options A, B, and C are less relevant in this scenario. Sleep apnea typically causes daytime fatigue rather than resistance to bedtime. Assessing vital signs like blood pressure, pulse, and respirations is unlikely to provide insights into the child's sleep patterns. Monitoring REM sleep duration is not practical in a clinical setting and may not directly address the reported sleep issues in this case.

2. A client has been diagnosed with depression, and a nurse is assisting them. Which of the following is an example of a short-term outcome as part of the nursing process for this client?

• A. Client will verbalize that depression symptoms have lifted
• B. Client will identify life stressors that may be contributing to depression
• C. Client's insomnia will be resolved as evidenced by 8 hours of sleep each night
• D. Client will identify a mental health counselor in the community with whom they can meet for ongoing therapy

Correct answer: B

Rationale: In the nursing process for a client with depression, short-term outcomes are goals that need to be achieved before advancing towards long-term outcomes. Identifying life stressors that may be contributing to the depression is a crucial initial step. This process helps the client work through feelings of grief or sadness before moving on to long-term goals like therapy and depression management. Choice A is not a short-term outcome as the lifting of depression symptoms is usually a long-term goal. Choice C focuses on resolving insomnia, which is a symptom of depression, but not directly addressing the root cause. Choice D involves identifying a mental health counselor for ongoing therapy, which is more aligned with a long-term treatment plan, rather than a short-term outcome.

3. An adolescent reports irregularity in menses. Her mother complains that her child often fears gaining weight, has poor caloric intake, and has a distorted self-image. Which could be the reason for irregular menses?

• A. Bulimia
• B. Anorexia
• C. Orthorexia
• D. Binge eating disorder

Correct answer: B

Rationale: The correct answer is 'Anorexia.' Anorexia is characterized by a lack of caloric intake motivated by a strong fear of gaining weight, leading to poor nutrition and potential irregular menses. Bulimia involves binge eating followed by compensatory behaviors. Orthorexia is characterized by an obsession with eating only healthy or 'pure' foods. Binge eating disorder is characterized by consuming large amounts of high-calorie food in a short period.

4. Which of the following is an example of non-reversible dementia?

• A. Pick's disease
• B. Syphilis
• C. Encephalopathy
• D. Hyperthyroidism

Correct answer: A

Rationale: Non-reversible dementia refers to a condition where individuals experience permanent and often progressive cognitive decline. Pick's disease is a type of non-reversible dementia characterized by changes in personality, behavior, and language difficulties. Syphilis (Choice B) is a reversible cause of dementia that can be treated with antibiotics. Encephalopathy (Choice C) is a broad term for brain dysfunction that can be reversible or irreversible depending on the cause. Hyperthyroidism (Choice D) can lead to cognitive impairment but is reversible with appropriate treatment. Therefore, Pick's disease is the correct example of non-reversible dementia among the options provided.

5. Which response would the nurse make to a client who says, 'The voices say I'll be safe only if I stay in this room, wear these clothes, and avoid stepping on the cracks between the floor tiles'?

• A. Ask whether the voices are male or female and how many there are.
• B. Reassure the client by stating, 'I understand that these voices are real to you, but I want you to know that I don't hear them.'
• C. Offer false reassurance by saying, 'Don't worry"?I've locked the door to your room and won't let anyone in.'
• D. Encourage the client to leave the room and keep busy to distract from the voices.

Correct answer: B

Rationale: The response, 'I understand that these voices are real to you, but I want you to know that I don't hear them,' demonstrates empathy and validation of the client's experience while also gently bringing in the nurse's reality. This response acknowledges the client's feelings without reinforcing the hallucinations. Asking about the characteristics of the voices (Choice A) can inadvertently validate the hallucinations. Offering false reassurance (Choice B) may not be helpful as it does not address the client's distress. Encouraging the client to leave the room and keep busy (Choice D) is nontherapeutic as it disregards the client's experience and may increase anxiety.

Similar Questions