LVN Psychosocial Integrity Flashcards

A toddler has sustained an injury. Which of the following injuries is MOST LIKELY the result of child abuse?

Answer: Several small, dime-sized circular burns on the child's back

Several small, dime-sized circular burns on a child's back are highly suspicious for child abuse. This pattern often indicates contact with a hot object like a cigarette or a specific tool, suggesting intentional harm. Accidental burns typically have irregular shapes and are not uniformly circular in multiple locations.

Which of the following is a defense mechanism that is described as withdrawing into passivity and becoming inaccessible so as to avoid further threatening situations?

Answer: Insulation

Insulation, as a defense mechanism, involves withdrawing emotionally and becoming detached or inaccessible to avoid threatening situations or overwhelming feelings. It's a way of creating a psychological barrier to protect oneself from further hurt or stress. This differs from other mechanisms like identification, suppression, or projection, which involve different coping strategies.

During an initial assessment, a client reports the following behaviors: social inhibition, hypersensitivity to negative evaluation, fear of criticism, and social ineptitude. The nurse suspects which of the following personality disorders?

Answer: Avoidant

The described behaviors—social inhibition, hypersensitivity to negative evaluation, fear of criticism, and social ineptitude—are classic symptoms of Avoidant Personality Disorder. Individuals with this disorder desire social interaction but are intensely afraid of rejection and humiliation, leading them to avoid social situations. Other personality disorders present with different core features.

A client is in the first stage of Alzheimer's disease. The nurse should plan to focus this client's care on:

Answer: providing emotional support and individual counseling

In the first stage of Alzheimer's disease, clients often experience mild cognitive decline but are still aware of their condition and its implications. During this stage, providing emotional support, reassurance, and individual counseling helps them cope with the diagnosis, manage anxiety, and adjust to changes. Nutritional issues or major illnesses are more common in later stages.

The mother of a 7-year-old asks about the administration of the booster immunizations while the child has an upper respiratory infection. The nurse should understand what?

Answer: Active immunologic vaccines are not given to clients with an upper respiratory infection.

Generally, active immunologic vaccines are not administered to individuals experiencing an acute illness, such as an upper respiratory infection, especially if accompanied by a fever. The body's immune system is already engaged in fighting the infection, and administering a vaccine could potentially reduce its effectiveness or exacerbate symptoms. It's best to wait until the child has recovered to ensure optimal vaccine efficacy and minimize adverse reactions.

The nurse is caring for a 58-year-old client with hypothyroidism. Which type of diet should the nurse expect to be ordered for the client?

Answer: Low calorie diet

Hypothyroidism causes a decrease in metabolic rate, which often leads to weight gain. Therefore, a low-calorie diet is typically recommended to help manage weight and prevent further weight gain in clients with this condition. This dietary approach supports the overall management of hypothyroidism symptoms.

You have a patient in your unit who has cirrhosis. He is experiencing a fluid volume excess as a result of this disease. Which of the following nursing interventions would NOT be taken for this patient?

Answer: Replacement of fluids isotonically, preferably orally

For a patient experiencing fluid volume excess due to cirrhosis, the primary goal is to restrict fluids, not replace them. Administering isotonic fluids, whether orally or intravenously, would exacerbate the existing fluid overload. This would worsen symptoms like ascites and edema, making it a contraindicated intervention.