Nokea
Obsessions are thoughts that are unwanted and known to be incorrect
- A. TRUE
- B. FALSE
Correct Answer: A
Rationale: Obsessions are intrusive, unwanted thoughts recognized by the individual as irrational or excessive.
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A 76-year-old is regressed, indifferent, and responds to others only when they initiate an interaction. What form of group therapy would be most useful to promote resocialization?
- A. Remotivation
- B. Activity group
- C. Psychotherapy
- D. Reminiscence (life review)
Correct Answer: A
Rationale: Remotivation therapy helps to resocialize regressed and apathetic patients by focusing on a single topic, creating a bridge to reality as group members talk about the world in which they live and work and hobbies related to the topic. Group leaders give members acceptance and appreciation. Group psychotherapy would not be effective for this patient. An activity group does not address the patients problem.
Delusional thinking is characteristic of
- A. psychosis
- B. obsessive-compulsive disorder
- C. conversion disorder
- D. fugue
Correct Answer: A
Rationale: Delusions are a hallmark of psychosis, indicating a break from reality.
A client on an antipsychotic medication develops a high fever, unstable blood pressure, and muscle rigidity. Her next dose of medication is due. The nurse should:
- A. Administer the medication and take the vital signs again
- B. Give a lower dose of the medication and take the blood pressure
- C. Prepare to give the pm anticholinergic, benztropine (Cogentin)
- D. Hold the medication and call the client's doctor immediately
Correct Answer: D
Rationale: The correct answer is D: Hold the medication and call the client's doctor immediately. This is the correct course of action because the client is exhibiting signs of neuroleptic malignant syndrome (NMS), a potentially life-threatening side effect of antipsychotic medications. Holding the medication is essential to prevent further complications. Calling the doctor is necessary to inform them of the situation and seek further instructions. Administering the medication (choice A) would exacerbate the symptoms, giving a lower dose (choice B) is not sufficient in this emergency situation, and administering an anticholinergic (choice C) is not the appropriate response for NMS.
Which nursing intervention has highest priority for a patient with bulimia nervosa?
- A. Assist the patient to identify triggers to binge eating.
- B. Provide remedial consequences for weight loss.
- C. Assess for signs of impulsive eating.
- D. Explore needs for health teaching.
Correct Answer: A
Rationale: The correct answer is A: Assist the patient to identify triggers to binge eating. The highest priority for a patient with bulimia nervosa is addressing the root cause of the behavior, which is often triggered by emotional or situational factors. By identifying triggers, the patient can learn to recognize and manage them effectively, ultimately reducing the frequency of binge eating episodes. This intervention focuses on addressing the underlying issue and promoting long-term recovery.
Summary:
B: Providing remedial consequences for weight loss is not the priority as the main concern is addressing the binge eating behavior.
C: Assessing for signs of impulsive eating is important, but identifying triggers takes precedence in addressing the behavior.
D: Exploring needs for health teaching may be relevant, but addressing triggers to binge eating is more immediate and crucial for managing bulimia nervosa.
During morning care, the nursing assistant asks a patient with dementia, 'How was your night?' The patient replies, 'It was lovely. My husband and I went out to dinner and to a movie.' The nurse who overhears this should make the assessment that the patient is:
- A. Demonstrating a sense of humor.
- B. Using confabulation.
- C. Perseverating.
- D. None of the above.
Correct Answer: B
Rationale: The correct answer is B: Using confabulation. Confabulation is when a person with dementia unknowingly creates fictitious memories to fill in gaps in their memory. In this scenario, the patient's response of going out to dinner and a movie with their husband is not based in reality, indicating confabulation. A: Demonstrating a sense of humor is incorrect because the patient is not intentionally being humorous. C: Perseverating is incorrect as it refers to repeating the same words or phrases, which is not evident in the patient's response. D: None of the above is incorrect as the patient's response aligns with confabulation.