A 14-year-old belongs to a gang that bullies and punishes other teens, engages sexually promiscuous behaviour, attends school infrequently and argues with her parents, claiming they are just old-fashioned and don't understand her. What does the assessment data support about the patient?
That she cannot accurately appraise reality
That she is exhibiting problems related to conduct and behaviour
That she is seriously and persistently mentally ill
That she should be considered for group home placement
The Correct Answer is B
Reasoning:
Choice A reason: There is no evidence in the provided data suggesting the patient is experiencing psychosis, hallucinations, or a break from reality. Her behaviors, while maladaptive and antisocial, are volitional and goal-directed within her peer group. Her arguments with parents reflect interpersonal conflict rather than an inability to appraise reality.
Choice B reason: The patient's behaviors, including bullying, truancy, and promiscuity, are hallmark clinical features of conduct disorder or significant behavioral issues. These actions violate the basic rights of others and major societal norms. The assessment data directly supports a diagnosis related to externalizing behavioral problems and conduct disturbances.
Choice C reason: Serious and persistent mental illness usually refers to long-term disorders like schizophrenia or bipolar disorder that significantly impair functional capacity over a lifetime. While her behavior is problematic, the data provided describes a behavioral pattern typical of adolescent conduct issues rather than a chronic, debilitating neurobiological illness.
Choice D reason: While group home placement might eventually be considered, it is a treatment intervention rather than an assessment finding. The question asks what the assessment data supports about the patient's condition. The data supports a behavioral diagnosis; determining the specific level of residential care requires further comprehensive social evaluation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Reasoning:
Choice A reason: Visitor education is a necessary supportive measure to prevent the introduction of contraband, such as glass, sharp objects, or medications, onto the unit. However, it is an indirect intervention that relies on the compliance of third parties and does not provide active, continuous monitoring of the patient.
Choice B reason: Removing harmful personal items, such as belts, shoelaces, and razors, is a standard environmental safety precaution known as "ligature risk reduction." While helpful, patients with high suicidal intent can often find ways to use seemingly innocuous items or environmental features to attempt self-harm.
Choice C reason: Restricting access to high-risk areas, such as kitchens or utility rooms, limits the patient's means of self-harm. However, it does not address the patient's behavior within the "safe" areas of the unit. Environmental restriction is a passive intervention that is less effective than active, human-led supervision.
Choice D reason: One-to-one observation is the most effective intervention because it provides constant, immediate, and direct monitoring of the patient’s actions. This allows staff to intervene the very second a patient attempts a self-harming behavior, offering the highest level of accountability and immediate physical safety.
Correct Answer is C
Explanation
Reasoning:
Choice A reason: Asking the patient what they think about their weight assesses body image perception and cognitive distortion, which is important for diagnosing the type of eating disorder. However, it does not provide objective data about the patient's actual nutritional intake or specific "eating patterns" mentioned in the question.
Choice B reason: This question also targets the psychological aspect of the disorder—specifically the intense fear of weight gain or distorted body perception. While crucial for a holistic assessment, it is a subjective emotional inquiry rather than a functional assessment of the patient's daily caloric intake and dietary behaviors.
Choice C reason: To assess eating patterns, the nurse needs objective information about what the patient consumes. Asking for a typical day’s intake provides concrete data on food choices, portion sizes, meal frequency, and potential restriction. This is the most direct way to evaluate the nutritional status and the severity of the restriction.
Choice D reason: Knowing who plans family meals can provide insight into the patient's level of control or the social environment surrounding food. However, it is a secondary piece of information that does not reveal the patient's actual consumption or the specific patterns of eating that led to a 15 kg weight loss.
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