The nurse is caring for a client diagnosed with Severe Intellectual Disability. Which of the following characteristics should the nurse recognize to be associated with Severe Intellectual Disability?

Other than possible coordination problems, the client's psychomotor skills are not affected.

The client communicates wants and needs by "acting out behaviors.”

The client can perform some self-care activities independently.

The client has advanced speech development.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Other than possible coordination problems, the client's psychomotor skills are not affected. Severe Intellectual Disability (ID) is characterized by significant limitations in intellectual functioning as well as adaptive behaviors. Coordination problems are not a primary characteristic of severe ID. The main focus is on cognitive and adaptive deficits.

Choice B rationale:

The client communicates wants and needs by "acting out behaviors." Severe ID can lead to challenges in effective communication. "Acting out behaviors" such as tantrums, aggression, or other disruptive actions might be the client's way of expressing themselves when they are unable to communicate verbally or effectively due to their cognitive limitations.

Choice C rationale:

The client can perform some self-care activities independently. Severe ID typically involves significant impairments in adaptive functioning, which includes self-care activities. The ability to perform some self-care activities independently is not consistent with the characteristics of severe ID.

Choice D rationale:

The client has advanced speech development. Severe ID is associated with delayed or impaired speech and language development. Advanced speech development would be contradictory to the diagnosis of severe ID, as this condition is characterized by substantial limitations in communication skills.

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Correct Answer is C

Explanation

Choice A rationale:

Instructing the client to tell the voices to leave them alone oversimplifies the situation. It disregards the distress and lack of control that individuals with schizophrenia often experience when hearing voices. This response may also imply that the client has complete control over the voices, which is not accurate.

Choice B rationale:

Denying the existence of the voices contradicts the client's experience and could lead to further distrust between the client and nurse. Acknowledging the client's feelings and experiences is essential for building rapport and understanding in a therapeutic relationship.

Choice C rationale:

This response is appropriate because it acknowledges the client's experience and seeks to understand the content and nature of the voices. It demonstrates empathy and encourages open communication, which is crucial in providing effective care for individuals with schizophrenia.

Choice D rationale:

Asking the client why they think they are hearing the voices might be interpreted as confrontational or judgmental. It could make the client defensive and hinder open communication. Instead, focusing on the content of the voices allows the nurse to gain insight into the client's experiences without placing blame.

A. Ask the client for permission to take photographs. B. Provide community sexual assault support contacts. C. Document the client's verbatim statements. D. Determine any physical signs of injury.

Correct Answer is C

Explanation

Answer: c. Document the client's verbatim statements.

Here's why the other options are wrong:

a. Ask the client for permission to take photographs:While photographs may be collected as evidence later, it should not be the first priority. The priority is to focus on patient care and emotional well-being.
b. Provide community sexual assault support contacts:Offering support resources is important, but documenting the details of the assault is crucial for forensic and legal purposes, and should come first.
d. Determine any physical signs of injury:Looking for physical injuries is important, but documenting the client's account should come first. This ensures the client's narrative is captured accurately and can be referred to later.

Documenting the client's verbatim statements is the most important initial action because:

It preserves the client's account of the assault in their own words.
It allows for accurate reporting and investigation.
It can be used as evidence in legal proceedings.

Here are some supporting points:

The Rape, Abuse & Incest National Network (RAINN):"Law enforcement will need to take a detailed statement about the assault, and a medical professional will likely perform a physical exam. Be prepared to answer questions about what happened." [1]
The National Sexual Assault Hotline:"Law enforcement will want to get a statement from you as soon as possible after the assault. Try to remember the details of the assault as clearly as you can." [2]

In conclusion, while all the other options are important aspects of caring for a sexual assault survivor, documenting the client's verbatim statements is the most critical initial action for a nurse to take in the emergency department setting.

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The nurse is caring for a client diagnosed with Severe Intellectual Disability. Which of the following characteristics should the nurse recognize to be associated with Severe Intellectual Disability?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is talking with a client diagnosed with schizophrenia. Suddenly the client states, "I'm frightened. Do you hear that? The voices are telling me to do terrible things." Which of the following responses by the nurse is appropriate?

Correct Answer is C

Explanation

A nurse in an emergency department is performing an assessment on a client who reports being sexually assaulted. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

A nurse is caring for a client diagnosed with a mental illness on a psychiatric unit. Which of the following actions by the nurse demonstrates the ethical concept of autonomy?

The nurse is asking a diagnosed schizophrenic patient how they slept and they respond, "This is a new day in May and I can't wait to play." Which communication pattern does the nurse identify?

The community health nurse recognizes that which of the following mental health issues is most prevalent in the homeless population?

A nurse educator is discussing community mental health with a group of nursing students. Based on the public health model, which of the following statements made by one of the students indicates correct information about primary prevention?

A nurse is caring for a client who requires crisis intervention for acute anxiety. Which of the following nursing actions is the highest priority?

A nurse at a walk-in mental health clinic is assessing a client experiencing severe anxiety. The nurse should recognize the client might exhibit which of the following manifestations?

A school nurse is talking with a 13-year-old female at her annual health-screening visit. Which of the following comments made by the adolescent should be the nurse's priority to address?

The nurse is reviewing the records of a child diagnosed with autistic spectrum disorder (ASD). Which of the following client outcomes should the nurse recognize as realistic for a client diagnosed with ASD?