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A patient presents to the emergency department with mixed psychiatric symptoms. The admission nurse suspects the symptoms may be the result of a medical problem. Lab results show elevated BUN (blood urea nitrogen) and creatinine. What is the nurse’s next best action?
- A. Report the findings to the health care provider.
- B. Assess the patient for a history of renal problems.
- C. Assess the patient’s family history for cardiac problems.
- D. Arrange for the patient’s hospitalization on the psychiatric unit.
Correct Answer: A
Rationale: Rationale for Correct Answer (A): Reporting the findings to the health care provider is the next best action because elevated BUN and creatinine levels indicate possible renal dysfunction, which could be causing the psychiatric symptoms. The health care provider needs this information to determine appropriate treatment and further evaluation.
Summary of Incorrect Choices:
B: Assessing the patient for a history of renal problems is not the next best action because the lab results already indicate potential renal issues.
C: Assessing the patient’s family history for cardiac problems is irrelevant to the elevated BUN and creatinine levels and the psychiatric symptoms.
D: Arranging for the patient’s hospitalization on the psychiatric unit is premature without addressing the underlying medical issue indicated by the lab results.
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The mother of a child describes her child's annoying behavior as not being able to sit still or to stop jerking his arms when told to. Which disorder does the nurse suspect?
- A. Oppositional-defiant disorder
- B. Tourette’s disorder
- C. Oppositional-defiant disorder
- D. What makes you think he is doing that out of defiance?
Correct Answer: B
Rationale: The correct answer is B: Tourette’s disorder. The child's inability to sit still and jerking arms suggest motor tics, which are common in Tourette's disorder. Tourette's is characterized by involuntary repetitive movements or sounds. Choice A is incorrect as oppositional-defiant disorder does not involve physical tics. Choice C is a duplicate. Choice D is incorrect as it assumes defiance rather than considering a neurological explanation for the behavior.
A newly admitted patient diagnosed with major depression has gained 20 pounds over a few months and has suicidal ideation. The patient has taken an antidepressant medication for 1 week without remission of symptoms. Select the priority nursing diagnosis.
- A. Imbalanced nutrition: more than body requirements.
- B. Chronic low self-esteem.
- C. Risk for suicide.
- D. Hopelessness.
Correct Answer: C
Rationale: The priority nursing diagnosis in this case is C: Risk for suicide. This is because the patient is exhibiting suicidal ideation, which poses an immediate threat to their safety and well-being. Suicidal ideation requires urgent intervention to ensure the patient's safety. The patient's major depression, weight gain, and lack of symptom remission from the antidepressant medication further emphasize the seriousness of the situation. Choices A, B, and D are not the priority in this scenario as they do not address the immediate risk of harm to the patient. Imbalanced nutrition and chronic low self-esteem are important concerns but do not take precedence over the risk of suicide. Hopelessness, while relevant, is not as urgent as addressing the immediate risk of suicide.
When a novice nurse asks why the unit has a multidisciplinary approach to therapeutic activities, the nurse should explain that multidisciplinary collaboration:
- A. Reduces the incidence of aggressive behavior by patients
- B. Produces quicker results and earlier discharge to the community
- C. Produces better outcomes than when only one perspective is used
- D. Helps to improve staffing efficiency and resource allocation.
Correct Answer: C
Rationale: Rationale for Correct Answer (C): Multidisciplinary collaboration in therapeutic activities involves the input of professionals from various disciplines, leading to a holistic approach that considers all aspects of a patient's condition. This approach is more likely to result in better outcomes because it combines diverse perspectives, expertise, and skills to address complex patient needs comprehensively.
Summary of Incorrect Choices:
A: Reducing aggressive behavior is not the primary goal of multidisciplinary collaboration in therapeutic activities.
B: While multidisciplinary collaboration may lead to efficient care, the primary focus is on achieving better outcomes rather than quicker discharge.
D: Although improving staffing efficiency and resource allocation may be benefits of multidisciplinary collaboration, the main purpose is to enhance patient care outcomes through diverse perspectives and expertise.
Which remark by one of the grief support group members would the nurse interpret as indicating unresolved feelings of guilt?
- A. The Christmas season is always a sad time for me.
- B. I know that my husband had a good life.
- C. It seems I miss my son more as time goes on.
- D. I am still wishing I had gotten help to him sooner.
Correct Answer: D
Rationale: The correct answer is D because expressing a wish for getting help sooner implies a sense of responsibility and guilt for not doing so. This indicates unresolved feelings of guilt. Choice A refers to sadness during a specific time of the year, not guilt. Choice B reflects acceptance and closure. Choice C indicates a natural progression of grief, not necessarily guilt.
The patient’s daughter was murdered while they were customers in a local bank. Which statements would support the patient’s diagnosis of posttraumatic stress disorder (PTSD)? Select all that apply:
- A. “I feel numb, like a robot going through the motions of existing.”
- B. “I’m so nervous and jump at the slightest noise.”
- C. “I have not slept very well at all since I lost her.”
- D. “I can’t stop reliving the last time I saw her alive.”
Correct Answer: A
Rationale: The correct answer is A because feeling numb and detached from emotions is a common symptom of PTSD known as emotional numbing. This symptom is often seen in individuals who have experienced a traumatic event, such as the murder of a loved one. It is a defense mechanism that helps the person cope with overwhelming emotions.
The other choices are incorrect:
B: Being nervous and easily startled (hypervigilance) is more indicative of the hyperarousal symptom of PTSD, not emotional numbing.
C: Difficulty sleeping is a common symptom of PTSD, known as insomnia, but it does not directly relate to emotional numbing.
D: Reliving the traumatic event through flashbacks or intrusive memories is a symptom of PTSD, but it is not directly related to emotional numbing.