Martha is a school nurse who is assessing an only child who had an outburst in class. It has been noted by the child's teacher that he is having difficulty focusing in class. When he gets frustrated, he sometimes loses his temper and the teacher is afraid he might hurt himself or someone else. What might some of the child's symptoms indicate?

Correct Answer: B

Rationale: The correct answer is B: undiagnosed ADHD. The child's difficulty focusing, outbursts, and impulsive behavior are common symptoms of ADHD. ADHD can lead to emotional dysregulation, which may result in temper outbursts and difficulty controlling emotions. The child's behavior is not indicative of a learning disability (A) as it primarily involves attention and behavior rather than academic challenges. It is also not a normal developmental phase (C) as the symptoms are impacting the child's ability to function in the classroom. Lastly, the behavior is not solely due to being an only child (D) as it does not address the underlying neurological factors associated with ADHD.

Correct Answer: C

Rationale: The correct answer is C: Nurse-patient relationship. Building a strong therapeutic alliance is crucial in addressing the patient's poor social skills. A trusting relationship with the nurse can provide a safe space for the patient to explore and improve their social interactions. The nurse can offer guidance, support, and feedback to help the patient develop social skills. Self-help and recovery groups may be beneficial later on, but initially, the focus should be on building a therapeutic relationship. Limit setting is not directly related to improving social skills and may not address the underlying issues contributing to the patient's difficulties.

Correct Answer: B

Rationale: The correct answer is B: undiagnosed ADHD. The child's difficulty focusing, outbursts, and impulsive behavior are common symptoms of ADHD. ADHD can lead to emotional dysregulation, which may result in temper outbursts and difficulty controlling emotions. The child's behavior is not indicative of a learning disability (A) as it primarily involves attention and behavior rather than academic challenges. It is also not a normal developmental phase (C) as the symptoms are impacting the child's ability to function in the classroom. Lastly, the behavior is not solely due to being an only child (D) as it does not address the underlying neurological factors associated with ADHD.

Correct Answer: B

Rationale: The correct answer is B: assessment; care planning. Maslow's theory is used in nursing assessment to prioritize patient needs based on the hierarchy of needs. Rogers's theory focuses on establishing a therapeutic relationship, which informs care planning. Evaluation (choice A) is not directly linked to Maslow's or Rogers's theories. Reflection (choice C) and self-awareness (choice D) are more related to personal growth and therapeutic communication rather than specific nursing practices.

Correct Answer: B

Rationale: Correct Answer: B Rationale: In Maslow's hierarchy of needs, the lowest level is physiological needs which include safety needs. Choice B reflects maintaining physical safety, which is a fundamental requirement for survival. This is prioritized before self-actualization (choice A), love and belonging (choice C), and esteem needs (choice D). Therefore, choice B is the correct answer as it aligns with the foundational aspect of Maslow's hierarchy. Summary of Other Choices: - A: Discussing all points of view and possessing ethics falls under self-actualization, a higher-level need. - C: Establishing interpersonal relationships and group identity falls under love and belonging needs, a higher-level need. - D: Desiring prestige from personal accomplishments falls under esteem needs, a higher-level need.