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A client is diagnosed with somatic symptom disorder. Which question will help the nurse develop nursing diagnoses for this client's plan of care?
- A. Are you satisfied with your appearance?
- B. Do you take medication for anxiety as prescribed?
- C. When did you last feel detached from your environment?
- D. How long have you had these memory problems?
Correct Answer: B
Rationale: In clients with somatic symptom disorder, it is crucial to assess their adherence to medication for anxiety as prescribed. This question helps the nurse understand the client's treatment compliance, which can impact the development of nursing diagnoses and the overall plan of care. Monitoring medication adherence is essential in managing the client's symptoms and improving outcomes.
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A nursing instructor is teaching a group of students about intimate partner violence. Which response by the students indicates no further teaching is needed?
- A. Alaska Native women report the highest rate of intimate partner violence.
- B. Caucasian women report the lowest rate of intimate partner violence.
- C. African American women report the highest rate of intimate partner violence.
- D. Asian women report the lowest rate of intimate partner violence.
Correct Answer: A
Rationale: The correct answer is A. Alaska Native women do report the highest rate of intimate partner violence. This statistic is important for healthcare professionals to be aware of to provide culturally sensitive care and interventions. Choices B, C, and D are incorrect statements. While it is essential to understand disparities in intimate partner violence rates among different populations, in this context, the focus is on recognizing the accurate information provided about Alaska Native women.
A 10-year-old boy breaks his mother's vase while playing. When the mother asks who broke the vase, the little boy says that his sister did it. The little boy is exhibiting which defense mechanism?
- A. Projection
- B. Displacement
- C. Dissociation
- D. Sublimation
Correct Answer: A
Rationale: Projection is a defense mechanism where one attributes their own unacceptable thoughts, feelings, or impulses onto another person. In this scenario, the little boy is projecting his actions onto his sister by falsely claiming she broke the vase. Displacement involves transferring emotions from the original source to a substitute target. Dissociation is a disconnection between thoughts, identity, consciousness, and memory. Sublimation is the redirection of unacceptable impulses into socially acceptable activities.
While auditing care plans for clients with eating disorders, the nurse realizes that a nursing diagnosis appropriate for a client with anorexia nervosa as well as for a client with bulimia nervosa is
- A. Risk for imbalanced body temperature
- B. Ineffective denial
- C. Chronic low self-esteem
- D. Adult failure to thrive
Correct Answer: C
Rationale: Chronic low self-esteem is a nursing diagnosis that can be applicable to clients with both anorexia nervosa and bulimia nervosa. These eating disorders are often associated with distorted body image, feelings of inadequacy, and low self-esteem. Clients with these conditions may engage in harmful behaviors related to their self-image, making chronic low self-esteem a relevant nursing diagnosis for them.
During a treatment team meeting, the point is made that a client with schizophrenia has recovered from the acute psychosis but continues to demonstrate apathy, avolition, and blunted affect. The nurse who relates these symptoms to serotonin excess will suggest that the client receive?
- A. Chlorpromazine
- B. Phenelzine
- C. Haloperidol
- D. Olanzapine
Correct Answer: D
Rationale: In this scenario, the symptoms of apathy, avolition, and blunted affect are indicative of negative symptoms commonly seen in schizophrenia. These symptoms are often associated with dopamine and serotonin imbalances in the brain. Olanzapine, an atypical antipsychotic, is known for its efficacy in treating both positive and negative symptoms of schizophrenia. It acts by blocking serotonin and dopamine receptors, helping to alleviate the symptoms mentioned. Chlorpromazine and Haloperidol are typical antipsychotics that primarily target dopamine receptors, while Phenelzine is an MAOI used to treat depression and anxiety disorders, not schizophrenia. Therefore, the most appropriate choice for this client displaying these symptoms related to serotonin excess would be Olanzapine.
A client is experiencing progressive changes in memory that have interfered with personal, social, and occupational functioning. The client exhibits poor judgment and has a short attention span. The nurse recognizes these as classic signs of which condition?
- A. Delirium
- B. Mania
- C. Parkinsonism
- D. Alzheimer's
Correct Answer: D
Rationale: The client's presentation of progressive memory changes, poor judgment, and attention deficits align with classic signs of Alzheimer's disease. Alzheimer's is a neurodegenerative disorder characterized by cognitive decline that significantly impacts daily functioning. While delirium and mania may present with cognitive changes, Alzheimer's is specifically associated with progressive memory loss and cognitive impairment over time.