Nokea
The nurse has been working with a patient diagnosed with schizophrenia who experiences auditory hallucinations. The patient relates, 'When I first heard the voices they said nice things about me. Lately, they've changed and they say bad things.' What information has the least impact on therapeutic patient care at this point in the hospitalization?
- A. Do you trust me to help you with the voices?'
- B. Are the voices commanding you to do something?'
- C. How often during 24 hours do you hear the voices?'
- D. Do you hear the voices if you're busy in noisy environment?'
Correct Answer: A
Rationale: Rationale for Correct Answer (A): Asking the patient if they trust the nurse to help with the voices is the least impactful at this point because establishing trust should have already been a priority earlier in the hospitalization. The focus now should be on assessing the nature and frequency of the auditory hallucinations to guide further treatment and intervention.
Summary of Incorrect Choices:
B: This question is important to assess if the voices are commanding potentially harmful actions.
C: Understanding the frequency of the voices is crucial in evaluating the severity of the symptoms.
D: Inquiring about hearing voices in different environments helps assess the impact of external factors on the hallucinations.
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A 91-year-old female client with dementia is being seen by the home health nurse. Both she and her husband, who is 92 years old, were very active until her dementia became debilitating. Since that time, the client does not recognize her husband or children, forgets how to eat and dress, and wanders about the house day and night. Her husband wants to keep her at home to care for her, but the nurse notices that he is increasingly tired with each visit. What is the nurse's priority intervention for the nursing diagnosis of caregiver role strain?
- A. Discuss strategies to coordinate care and other responsibilities
- B. Encourage involvement in support groups
- C. Identify resources to include financial, legal, and respite care
- D. Stress the importance of self-nurturing
Correct Answer: A
Rationale: The correct answer is A: Discuss strategies to coordinate care and other responsibilities. The priority intervention for caregiver role strain is to help the husband effectively manage caring for his wife with dementia. By discussing strategies to coordinate care and other responsibilities, the nurse can assist the husband in creating a plan to ensure the client's needs are met while also addressing his own well-being. This intervention will help alleviate the husband's increasing tiredness and provide support in managing the caregiving responsibilities.
Summary of other choices:
B: Encourage involvement in support groups - While support groups can be beneficial, the immediate priority is to address the husband's caregiving responsibilities.
C: Identify resources to include financial, legal, and respite care - While important, these resources may not directly address the husband's current strain in caring for his wife.
D: Stress the importance of self-nurturing - While self-care is important, the immediate focus should be on assisting the husband in managing his caregiving responsibilities.
The risk for developing the condition is about 50% only if both parents were carriers of the gene that predisposes the condition to their offspring.
- A. The risk is 25% if only one parent is a carrier.
- B. The risk is 50% if both parents are carriers.
- C. The risk is 75% if both parents are carriers.
- D. None of the above.
Correct Answer: B
Rationale: The correct answer is B. If both parents are carriers of a gene that predisposes a condition, each parent contributes one copy of the gene, resulting in a 50% chance that the offspring will inherit the gene from both parents, leading to a 50% risk of developing the condition. Choice A is incorrect because if only one parent is a carrier, the offspring has a 25% chance of inheriting the gene. Choice C is incorrect as the risk is not 75% when both parents are carriers, but rather 50%. Choice D is also incorrect as the risk is indeed 50% when both parents are carriers.
A nurse and social worker co-lead a reminiscence group for eight elite-old adults. Which activity is appropriate to include in the group?
- A. Mild aerobic exercise
- B. Singing a song from World War II
- C. Discussing national leadership during the Vietnam War
- D. Identifying the most troubling story in todays newspaper
Correct Answer: B
Rationale: Elite-old adults (100+ years) were young during World War II. Singing a song from that era (B) aligns with reminiscence therapy by sharing relevant past memories. Other options (A, C, D) are less tied to their life experiences.
Disorders which are characterised by serious abnormalities in the developmental process, fall under the heading of pervasive developmental disorders (PDD) and are usually associated with impairment in several areas of development. From early infancy, some children will exhibit a spectrum of developmental impairments and delays that include which of the following?
- A. Social and emotional disturbances
- B. Intellectual disabilities
- C. Language and communication deficits
- D. All of the above
Correct Answer: D
Rationale: Pervasive Developmental Disorders (PDDs): Characterized by serious developmental abnormalities affecting social, intellectual, and communication skills.
The nurse who assesses a patient previously diagnosed as having paranoid personality disorder is most likely to describe the patient as:
- A. superficially charming.
- B. intense and impulsive.
- C. guarded and distant.
- D. friendly and open.
Correct Answer: C
Rationale: The correct answer is C: guarded and distant. This is because individuals with paranoid personality disorder typically exhibit suspiciousness, mistrust, and a reluctance to confide in others. They tend to be hypervigilant and wary of others, leading them to appear guarded and distant.
A: Superficially charming is incorrect because individuals with paranoid personality disorder are more likely to be cautious and suspicious rather than charming.
B: Intense and impulsive is incorrect as this description is more characteristic of individuals with borderline personality disorder, not paranoid personality disorder.
D: Friendly and open is incorrect because individuals with paranoid personality disorder are more likely to be reserved and cautious in their interactions.
In summary, the correct answer is C because individuals with paranoid personality disorder typically exhibit guarded and distant behavior due to their suspicious and mistrustful nature.