Signs such as using tissues to doorknobs develop because the patient is ________.

Correct Answer: A

Rationale: Signs such as using tissues to doorknobs suggest that the patient is unconsciously controlling unacceptable impulses or feelings. This behavior falls under the category of defense mechanisms, specifically displacement, where the individual redirects their emotions from a threatening target to a safer one. In this case, the patient may be experiencing anxiety or fear related to contamination or germs, leading them to use tissues to avoid touching doorknobs directly. It is a way for the patient to manage their underlying emotions, albeit unconsciously, through this compulsive behavior.

Correct Answer: D

Rationale: When performing an admission assessment, the nurse should expect to find clinical manifestations that are indicative of a variety of conditions. Paresthesia (abnormal sensation like tingling, prickling, or numbness) and muscle weakness of the upper body are commonly associated with neurological conditions such as peripheral neuropathy or cervical radiculopathy. These symptoms suggest dysfunction in the nerves that supply the upper body muscles, leading to sensory changes and weakness. This finding would prompt further assessment and evaluation by healthcare providers to determine the underlying cause and appropriate interventions. Rapid progressive muscular atrophy, ascending paralysis with ataxia, and hyperactive deep tendon reflexes are not typically expected findings during an admission assessment and may signal more specific neurological conditions such as amyotrophic lateral sclerosis, Guillain-Barré syndrome, or spinal cord injury, respectively.

Correct Answer: A

Rationale: Having a tracheostomy means that a patient has an artificial opening in their neck to help them breathe. Therefore, any issues related to breathing, such as blockages in the tracheostomy tube or difficulty in clearing secretions, can pose a major problem for a patient with a tracheostomy. It is crucial to monitor the patient's respiratory status closely and intervene promptly if any breathing difficulties arise to prevent potential respiratory distress or complications.

Correct Answer: D

Rationale: Consistent limit setting is an effective nursing intervention for managing impulsive and aggressive behaviors in individuals with conduct disorder. By establishing clear and consistent boundaries, rules, and consequences, individuals with conduct disorder can learn self-control and appropriate behavior. Consistent limit setting provides structure and predictability, helping to reduce impulsive and aggressive reactions in these individuals. It also teaches them accountability for their actions and reinforces appropriate behavior. Additionally, setting limits helps to establish a sense of safety and security for both the individual and those around them. Therefore, consistent limit setting is a crucial intervention to help manage impulsive and aggressive behaviors associated with conduct disorder.

Correct Answer: C

Rationale: An assumption is a belief or statement that is accepted as true without proof. In this case, the statement suggests a belief that the length of service does not affect the degree of patient safety practices among staff nurses, without providing evidence or data to support this claim. It is an assumption about the relationship between two variables without a proper basis or evidence to back it up, making it an example of an assumption.