A nurse is conducting a group therapy session for several clients. The group is laughing at a joke one of the clients told, when a client who is schizophrenic jumps up and runs out of the room yelling. "You are all making fun of me!" The nurse should identify this behavior as which of the following characteristics of schizophrenia?

Looseness of association

ideas of reference

Magical thinking

Delusions of grandeur

Answer and Explanation

The Correct Answer is B

A. Looseness of association: Looseness of association refers to a thought disorder characterized by disorganized thinking and lack of logical connections between thoughts. It typically presents as disjointed or fragmented speech patterns, rather than misinterpreting social cues or actions of others.

B. Ideas of reference: Ideas of reference are a characteristic feature of schizophrenia involving the belief that external events, objects, or actions have special significance specifically directed at oneself. In this scenario, the client's belief that others laughing at a joke is directed towards them is an example of ideas of reference.

C. Magical thinking: Magical thinking involves the belief that one's thoughts, actions, or words can influence external events or outcomes. It is often associated with superstitions and rituals. While magical thinking can occur in schizophrenia, it is not specifically demonstrated in this scenario.

D. Delusions of grandeur: Delusions of grandeur involve false beliefs of one's own importance, power, or identity. While delusions of grandeur are a symptom of schizophrenia, they are not evident in this scenario, as the client's reaction is more related to misinterpretation of social cues rather than an exaggerated sense of self-importance.

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Free Nursing Study Resources

Correct Answer is ["90"]

Explanation

Answer:

below 90 beats per minute (bpm)

Rationale:

For infants, especially those receiving digoxin, the heart rate is a critical parameter to monitor due to the medication's potential to affect cardiac function.

The general guideline for withholding digoxin in infants is if the apical heart rate is below 90 beats per minute (bpm) in infants. Therefore, the nurse should withhold the dose if the infant's apical heart rate is less than 90 bpm.

It's important to note that specific institutional protocols may vary, so nurses should always adhere to the guidelines established by their facility. Additionally, if the infant's heart rate is below the threshold, the nurse should promptly notify the healthcare provider for further evaluation and guidance.

A. Provide a small electronic toy B. Change the infant's diaper as soon as soiling occurs. C. Allow the infant to stand in the crib D. The colorful latex balloons to the side of the crib

Correct Answer is A

Explanation

A. Provide a small electronic toy.

Providing a small electronic toy can engage the infant's senses and promote cognitive development. Interactive toys can stimulate the infant's curiosity, encourage exploration, and provide sensory stimulation, which are important aspects of infant development. However, the selection of toys should consider safety and age appropriateness, ensuring they do not pose a choking hazard or contain small parts that the infant could ingest.

B. Change the infant's diaper as soon as soiling occurs.

Changing the infant's diaper promptly when soiling occurs is essential for maintaining hygiene and preventing skin irritation or infection. However, while diaper changes are necessary for the infant's comfort and well-being, they primarily address basic needs rather than directly promoting growth and development related to the hip dysplasia.

C. Allow the infant to stand in the crib.

Allowing the infant to stand in the crib may not be suitable, especially if the infant is in a cast for developmental dysplasia of the hip (DDH). The cast is typically intended to maintain the hip joint in a specific position to promote proper alignment and development. Allowing the infant to stand in the crib could compromise the effectiveness of the treatment and potentially exacerbate the hip dysplasia. Therefore, this option is not appropriate.

D. Tie colorful latex balloons to the side of the crib.

Tying colorful latex balloons to the side of the crib is not recommended due to safety concerns. Latex balloons pose a choking hazard if they deflate or rupture, and the infant could accidentally ingest the latex material, leading to airway obstruction or other complications. Safety is paramount in infant care, and any potential hazards should be avoided.

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Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer digoxin to a 6-month-old infant. Prior to administering the dose, the nurse measures the apical heart rate. The nurse should withhold the dose if the infant's apical heart rate is less than what rate? below ___________ beats/min

Correct Answer is ["90"]

Explanation

A nurse is caring for a 10-month-old infant who is in a cast for developmental dysplasia of the hip (DDH). Which of the following strategies should the nurse implement to promote the infant's growth and development?

Correct Answer is A

Explanation

A nurse observes that a client who has depression is sitting alone in the room crying. As the nurse approaches, the client states, "I'm feeling really down and don't want to talk to anyone right now." Which of the following responses should the nurse make?

A nurse is caring for a client who has severe manifestations of schizophrenia and is medicated PRN for agitation with haloperidol. The nurse should assess the client for which of the following adverse effects?

A nurse is planning discharge for a client who has borderline personality disorder. Which of the following interventions should be included for this client?

A nurse is collecting data from a child who is descending stairs by placing both feet on each step and holding on to the railing. The nurse should understand that these actions are developmentally appropriate at which of the following ages?

A nurse who works in a psychiatric unit is caring for a client who has bipolar disorder. The client comes to the nurse's station at 0300 demanding that the nurse call the provider immediately. Which of the following responses by the nurse is appropriate?

A nurse is caring for a newborn whose mother voices concerns about sudden Infant death syndrome (SIDS). The nurse should include which of the following statements in a discussion with the mother?

A nurse is providing health promotion teaching to the parents of a toddler. Which of the following information should the nurse include in the teaching? (Select all that apply)

A nurse is caring for a client who has been diagnosed with obsessive compulsive disorder (OCD) and is constantly picking up after others in the day room. The nurse should recognize that the client uses this behavior to do which of the following?