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: B

Rationale: The correct answer is B. This response acknowledges the client's feelings, opens up communication, and allows the nurse to address specific concerns. It shows empathy and encourages the client to express their fears, leading to better understanding and support. Choice A is incorrect because offering medication without exploring the client's concerns may not address the root of their anxiety. Choice C is incorrect as it dismisses the client's feelings and suggests that their fears are unfounded. Choice D is incorrect because it focuses on the doctor's expertise, which may not alleviate the client's anxiety about the procedure.

Correct Answer: B

Rationale: Correct Answer: B Rationale: 1. Infancy's developmental task is trust vs. mistrust, forming trust in others. 2. Patient not allowing others to know them suggests inability to form trusting relationships. 3. Choice B aligns with the mistrust aspect of infancy development. 4. Choices A, C, D do not directly relate to the trust vs. mistrust developmental task.

Correct Answer: D

Rationale: The correct answer is D: coping strategies. This question is most relevant during the assessment of coping strategies because it directly pertains to how an individual copes with stress. By asking about the role of faith in stressful situations, the nurse can gain insight into the patient's coping mechanisms and support systems. This information can help tailor interventions to better support the patient's emotional and spiritual needs. A: childhood growth and development - This question is not directly related to childhood growth and development. B: substance use and abuse - This question focuses on a different aspect of the patient's life and does not address coping mechanisms. C: educational background - This question does not probe into the patient's coping strategies but rather focuses on their educational history.

Correct Answer: A

Rationale: The correct answer is A: Rationalization. Rationalization is a defense mechanism where individuals justify unacceptable behaviors or feelings by providing logical reasons or excuses. In this scenario, blaming the partner's attractiveness and romantic nature for one's sexual dysfunction is an example of rationalization. The individual is deflecting responsibility by attributing the issue to external factors. Summary of other choices: B: Compensation involves making up for a perceived weakness by emphasizing a strength. This is not evident in the scenario. C: Introjection involves internalizing external beliefs or values. Blaming the partner does not align with this defense mechanism. D: Regression involves reverting to an earlier stage of development in response to stress or conflict. This is not demonstrated in the scenario.