Why would a nurse establish goals for a client diagnosed with ADHD that allow the client to complete part of the task, rewarding each step completion with a break for physical activity?

Correct Answer: A

Rationale: The correct answer is A because breaking down tasks into smaller, manageable steps is beneficial for clients with ADHD who struggle with a short attention span. By setting short-term goals, the client is more likely to stay focused and motivated as they can see progress more frequently. This approach helps prevent the feeling of being overwhelmed by a large task. Choice B is incorrect because repetition of instructions is not directly related to breaking down tasks into smaller steps for better focus in ADHD clients. Choice C is incorrect because while the approach encourages independence, it does not specifically address the issue of managing a short attention span. Choice D is incorrect as it focuses on the client's ability to assimilate information rather than the strategy of setting achievable goals for individuals with ADHD.

Correct Answer: B

Rationale: The correct answer is B) Hallucinations. Hallucinations are false sensory perceptions that occur without a stimulus, meaning the person perceives something that is not actually present. In the context of this question, the client is experiencing sensory perceptions that have no basis in reality, indicating hallucinations. Delusions (option A) are false beliefs that are firmly held despite evidence to the contrary. Loose associations (option C) refer to a thought disorder where a person's speech is disjointed and lacks logical connections. Neologisms (option D) are made-up words that have no meaning to others. In an educational context, understanding the difference between these terms is crucial for healthcare professionals, especially nurses, who may encounter patients experiencing various mental health symptoms. Recognizing and correctly identifying hallucinations can guide appropriate interventions and care for the client. It also highlights the importance of thorough assessment and knowledge of mental health conditions in nursing practice.

Correct Answer: C

Rationale: The correct answer is C) Lack of self-esteem, strong dependency needs, and impulsive behavior. These nursing observations support the diagnosis of borderline personality disorder in the client. Borderline personality disorder is characterized by unstable relationships, self-image, and emotions. The client's history of quitting jobs due to interpersonal issues, destructive behavior like driving into a tree after an argument, and seeking help due to feeling depressed and abandoned align with the symptoms of borderline personality disorder. Option A) Flat affect, social withdrawal, and unusual dress are more indicative of symptoms seen in conditions like depression or social anxiety disorder, not specific to borderline personality disorder. Option B) Suspiciousness, hypervigilance, and emotional coldness are more aligned with symptoms of conditions like paranoid personality disorder or post-traumatic stress disorder, not typically seen in borderline personality disorder. Option D) Insensitivity to others, sexual acting out, and violence are more commonly associated with conditions like antisocial personality disorder or conduct disorder, not typically seen in borderline personality disorder. Educationally, understanding the specific symptoms and behaviors associated with different personality disorders is crucial for healthcare professionals to accurately assess and diagnose clients, as well as to provide appropriate interventions and support tailored to the individual's needs. Recognizing and interpreting these key observations can guide nursing care plans and interventions to effectively support individuals with borderline personality disorder.

Correct Answer: D

Rationale: The correct answer is option D) Takes a temporary job to maintain financial stability after the loss of a permanent job, as this individual is demonstrating the highest level of resilience. Resilience refers to the ability to adapt positively in the face of adversity or significant stressors. In this scenario, the individual is proactively taking steps to address the loss of a job by seeking temporary employment to ensure financial stability, showcasing resilience by actively problem-solving and adapting to the situation. Option A) One who is able to repress stressors is not demonstrating resilience but rather avoidance or suppression of emotions, which can lead to negative psychological outcomes in the long term. Resilience involves facing and processing stressors, not repressing them. Option B) Becoming depressed after the death of a spouse indicates a lack of resilience in coping with the emotional impact of the loss. While experiencing grief is normal, resilience would involve seeking support, engaging in coping strategies, and gradually adapting to the loss over time. Option C) Living in a shelter for 2 years after the home is destroyed by fire demonstrates endurance and adaptation to a challenging situation. However, the individual in option D is actively taking steps to improve their situation by finding employment, which shows a higher level of resilience in actively addressing and overcoming adversity. In an educational context, understanding resilience is crucial in promoting mental health and well-being. Teaching individuals how to develop resilience skills, such as problem-solving, seeking support, and maintaining a positive outlook during tough times, can help them navigate challenges effectively. By highlighting examples like option D where individuals demonstrate resilience, students can learn how to cultivate these skills in their own lives to better cope with stressors and setbacks.

Correct Answer: C

Rationale: The correct answer is C) Research shows that this condition more likely has a biological basis. Explanation: Schizophrenia is a complex mental disorder with a strong biological component. Research has shown that genetics, brain chemistry, and structural differences in the brain play significant roles in the development of schizophrenia. While environmental factors like childhood experiences may influence the expression of the disorder, they are not the primary cause. Understanding the biological basis of schizophrenia can help reduce stigma, promote effective treatment strategies, and encourage family members to support their loved one in seeking appropriate medical care. Why the other options are wrong: A) Psychological stress is not the sole basis for most mental disorders, including schizophrenia. While stress can exacerbate symptoms, it is not the primary cause of schizophrenia. B) Developmental factors may contribute to the manifestation of schizophrenia, but they do not outweigh the strong biological underpinnings of the disorder. D) This response does not address the spouse's question about the cause of schizophrenia and instead focuses on their feelings, missing an opportunity to provide valuable information about the disorder. Educational context: Understanding the factors contributing to mental health disorders is crucial for healthcare professionals, patients, and their families. By providing accurate information about the biological basis of schizophrenia, nurses can help debunk myths, reduce blame or guilt associated with the illness, and foster a supportive environment for individuals living with schizophrenia and their families. This knowledge can also guide treatment approaches and improve outcomes for patients.