Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is collecting data on an adolescent client who has attention deficit hyperactivity disorder (ADHD). Which of the following manifestations should the nurse expect to find?
A. Difficulty using words in context
Difficulty using words in context is not a symptom of ADHD, but of a language disorder or a learning disability that affects communication skills.
B. Difficulty performing self-grooming activities
Difficulty performing self-grooming activities is not a symptom of ADHD, but of a physical disability, a mental health disorder, or a lack of motivation or self-care.
C. Difficulty in acquiring reading skills
Difficulty in acquiring reading skills is not a symptom of ADHD, but of dyslexia, which is a specific learning disability that affects reading and spelling.
D. Difficulty maintaining sustained attention
Difficulty maintaining sustained attention is a common manifestation of ADHD, according to the American Psychiatric Association and the CDC. This means that people with ADHD often have trouble focusing on tasks or activities for a long period of time, especially if they are boring or tedious. The other choices are not manifestations of ADHD, but of other conditions or problems. Here are some reasons why:
This question is an excerpt from Nurse Dive's nursing test bank - PNU Adult Health II Spring 2023 Proctored Exam 2. Take the full exam now
Full Explanation
Difficulty maintaining sustained attention is a common manifestation of ADHD, according to the American Psychiatric Association and the CDC. This means that people with ADHD often have trouble focusing on tasks or activities for a long period of time, especially if they are boring or tedious.
The other choices are not manifestations of ADHD, but of other conditions or problems. Here are some reasons why:
Choice A: Difficulty using words in context is not a symptom of ADHD, but of a language disorder or a learning disability that affects communication skills.
Choice B: Difficulty performing self-grooming activities is not a symptom of ADHD, but of a physical disability, a mental health disorder, or a lack of motivation or self-care.
Choice C: Difficulty in acquiring reading skills is not a symptom of ADHD, but of dyslexia, which is a specific learning disability that affects reading and spelling.
Similar Questions
A nurse is collecting data from a client who has posttraumatic stress disorder (PTSD) following a sexual assault. Which of the following is an expected finding?
A. Increasing sense of attachment to others
This is not correct because the increasing sense of attachment to others is not a typical response to sexual assault. Survivors may experience difficulties in trusting or relating to others, especially those who remind them of the assault or who do not support them.
B. Increasing feelings of anger
Increasing feelings of anger is a common symptom of PTSD after a sexual assault, as survivors may feel violated, powerless, or betrayed by the perpetrator or others. Anger can also be a way of coping with fear, anxiety, or guilt that may arise from the trauma.
C. Constant need to talk about the event
This is not correct because the constant need to talk about the event is not a characteristic of PTSD. Survivors may avoid thinking or talking about the trauma, as it can trigger distressing emotions or memories. Some survivors may choose to share their experiences with others, but this does not indicate PTSD.
D. Sleeping 12 hr or more each day
This is not correct because sleeping 12 hr or more each day is not an expected finding of PTSD after a sexual assault. Survivors may have trouble falling or staying asleep, or experience nightmares or flashbacks that disrupt their sleep quality. Sleeping too much can also be a sign of depression, which can co-occur with PTSD.
Full Explanation
Increasing feelings of anger are a common symptom of PTSD after a sexual assault, as survivors may feel violated, powerless, or betrayed by the perpetrator or others. Anger can also be a way of coping with fear, anxiety, or guilt that may arise from the trauma.
Choice A is not correct because the increasing sense of attachment to others is not a typical response to sexual assault. Survivors may experience difficulties in trusting or relating to others, especially those who remind them of the assault or who do not support them.
Choice C is not correct because the constant need to talk about the event is not a characteristic of PTSD. Survivors may avoid thinking or talking about the trauma, as it can trigger distressing emotions or memories. Some survivors may choose to share their experiences with others, but this does not indicate PTSD.
Choice D is not correct because sleeping 12 hr or more each day is not an expected finding of PTSD after a sexual assault. Survivors may have trouble falling or staying asleep, or experience nightmares or flashbacks that disrupt their sleep quality. Sleeping too much can also be a sign of depression, which can co-occur with PTSD.
A nurse is assisting with the admission of a client to an acute mental health unit following a suicide attempt. The client has a history of depression, substance abuse, and anorexia nervosa. Which of the following actions should the nurse take first?
A. Initiate one-to-one nursing observation.
Initiate one-to-one nursing observation, as this is the most urgent intervention to ensure the safety of the client. The client has a history of depression, substance abuse, anorexia nervosa, and attempted suicide, which indicates that they are at high risk for harm to themselves. One-to-one observation involves an assigned staff member who will be with the client at all times, ensuring their safety and preventing any further self-harm attempts.
B. Make a contract with the client for weight gain.
Making a contract with the client for weight gain is not an appropriate first action as it does not address the client's immediate safety concerns.
C. Administer the Hamilton depression scale.
Administering the Hamilton depression scale may be important to assess the client's depressive symptoms but is not the most urgent priority.
D. Review the client's toxicology laboratory report.
Reviewing the client's toxicology laboratory report may be necessary for the overall assessment of the client, but safety comes first.
Full Explanation
initiate one-to-one nursing observation, as this is the most urgent intervention to ensure the safety of the client. The client has a history of depression, substance abuse, anorexia nervosa, and attempted suicide, which indicates that they are at high risk for harm to themselves. One-to-one observation involves an assigned staff member who will be with the client at all times, ensuring their safety and preventing any further self-harm attempts.
Choice B, making a contract with the client for weight gain, is not an appropriate first action as it does not address the client's immediate safety concerns.
Choice C, administering the Hamilton depression scale, may be important to assess the client's depressive symptoms but is not the most urgent priority.
Choice D, reviewing the client's toxicology laboratory report, may be necessary for the overall assessment of the client, but safety comes first.
A nurse is collecting data from a client who has obsessive-compulsive disorder (OCD) and finds that the client demonstrates constant repetitive cleaning. The nurse should realize that the client's repetitive behaviors occur due to which of the following?
A. The client's attempt to decrease anxiety.
As clients with obsessive-compulsive disorder (OCD) often demonstrate repetitive behaviors to decrease anxiety. Cleaning or other repetitive behaviors help the client with OCD to cope with their anxiety by providing a sense of control over their environment.
B. The client's wish to decrease the time available for interaction with others.
The client's wish to decrease the time available for interaction with others is not a characteristic of OCD and does not explain the client's behavior. Choice C, the client's unconscious need to manipulate others, is a personality trait that is not associated with OCD.
C. The client's unconscious need to manipulate others.
The client's unconscious need to manipulate others, is a personality trait that is not associated with OCD.
D. The client's delusion that cleaning is necessary.
The client's delusion that cleaning is necessary, is not an accurate explanation for the behavior in this situation as the client is aware of their excessive cleaning behavior and it is not a delusion. The repetitive behavior is related to the client's anxiety, not a delusional belief.
Full Explanation
As clients with obsessive-compulsive disorder (OCD) often demonstrate repetitive behaviors to decrease anxiety. Cleaning or other repetitive behaviors help the client with OCD to cope with their anxiety by providing a sense of control over their environment.
Choice B, the client's wish to decrease the time available for interaction with others, is not a characteristic of OCD and does not explain the client's behavior. Choice C, the client's unconscious need to manipulate others, is a personality trait that is not associated with OCD.
Choice D, the client's delusion that cleaning is necessary, is not an accurate explanation for the behavior in this situation as the client is aware of their excessive cleaning behavior and it is not a delusion. The repetitive behavior is related to the client's anxiety, not a delusional belief.