Age Specific Care

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A 28-year-old female client was admitted 3 days ago after she ran nude through the streets shouting that she was the 'Queen of Hearts.' Since admission, the client remains delusional, shouts obscenities, and demonstrates loosely associated thoughts. Based on these data, the nurse should develop a nursing diagnosis of:

  • A. Risk for violence
  • B. Defensive coping
  • C. Disturbed thought processes
  • D. Impaired memory
Correct Answer: C

Rationale: The correct answer is C: Disturbed thought processes. The client's behavior of being delusional, shouting obscenities, and demonstrating loosely associated thoughts indicates a disturbance in thought processes. This nursing diagnosis focuses on the client's cognitive functioning and perception of reality.

A: Risk for violence is not the most appropriate diagnosis in this case as there is no direct evidence of the client being a risk to herself or others.
B: Defensive coping does not address the client's specific symptoms of delusions and disorganized thinking.
D: Impaired memory is not the most appropriate diagnosis as the client's symptoms are more indicative of a broader disturbance in thought processes rather than just memory deficits.

Therefore, choice C is the most suitable nursing diagnosis based on the client's presentation of delusional behavior and disorganized thoughts.

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Which of the following assessments is most appropriate for a patient with anorexia nervosa?

  • A. Monitor fluid intake exclusively.
  • B. Check weight daily without discussing it with the patient.
  • C. Observe the patient's response to meals, including food refusal or purging behavior.
  • D. Monitor for signs of vitamin and mineral deficiencies.
Correct Answer: C

Rationale: The correct answer is C because observing the patient's response to meals, including food refusal or purging behavior, is crucial in assessing the patient's eating habits and behaviors associated with anorexia nervosa. This assessment helps in understanding the patient's relationship with food and identifying any disordered eating patterns. Monitoring fluid intake exclusively (Choice A) is not sufficient as it overlooks the broader aspects of the patient's eating behaviors. Checking weight daily without discussing it with the patient (Choice B) can be triggering and may not provide a comprehensive understanding of the patient's eating disorder. Monitoring for signs of vitamin and mineral deficiencies (Choice D) is important but does not directly address the specific behaviors associated with anorexia nervosa.

The antisocial personality is one who

  • A. is irresponsible and seems to lack remorse
  • B. is frequently dangerous and out of contact with reality
  • C. is always a delinquent or criminal
  • D. benefits greatly from humanistic and psychoanalytic therapies
Correct Answer: A

Rationale: Antisocial personality features irresponsibility and lack of remorse, not necessarily overt danger.

A patient reports an intense, overwhelming fear of driving a car. The fear has disrupted all elements of the patient's life. The patient does not go to the grocery store unless driven by someone else, has relinquished their job, and has few social contacts. The patient's treatment plan includes:

  • A. assertiveness training
  • B. biofeedback
  • C. stress management assistance
  • D. systematic desensitization
Correct Answer: D

Rationale: Systematic desensitization gradually exposes the patient to driving-related stimuli, reducing phobia through controlled steps.

A nursing intervention that will be planned to occur early in the nurse-patient relationship with a client with an eating disorder is:

  • A. formulating a nurse-client contract.
  • B. using confrontation to attack denial.
  • C. placing the client in a therapeutic group.
  • D. attacking enmeshment by separating client and family.
Correct Answer: A

Rationale: The correct answer is A: formulating a nurse-client contract. This intervention is essential early in the nurse-patient relationship with a client with an eating disorder because it establishes clear boundaries, roles, and expectations. By creating a contract, both the nurse and the client can communicate openly about their goals, responsibilities, and treatment plan. This helps build trust, promotes collaboration, and provides a framework for the therapeutic relationship.

Choices B, C, and D are incorrect:
B: Using confrontation to attack denial may be counterproductive and harmful in the early stages of the relationship as it can lead to resistance and damage trust.
C: Placing the client in a therapeutic group may be beneficial at a later stage but not necessarily an appropriate early intervention when individual needs should be addressed first.
D: Attacking enmeshment by separating client and family is not a suitable early intervention as it may cause distress and disrupt important support systems.

A 75-year-old male client is brought to the clinic by his son. The son states, 'Ever since Mom died, Dad hasn't been the same. At first he just seemed sad, but now he seems to get mixed up about everything.' The nurse is aware that based on the client's history, the source of confusion is most likely:

  • A. Dementia
  • B. Depression from the loss of his wife
  • C. Hypoxia of the brain
  • D. Delirium from medications
Correct Answer: B

Rationale: Correct Answer: B - Depression from the loss of his wife

Rationale: Given the client's recent loss of his wife and subsequent changes in behavior, the most likely cause of his confusion is depression. Depression can manifest as cognitive impairment in older adults, leading to symptoms such as confusion and memory problems. Additionally, grief and loss can exacerbate depressive symptoms in elderly individuals, further contributing to cognitive difficulties.

Summary of other choices:
A: Dementia - Dementia typically presents with gradual cognitive decline over time, not a sudden onset following a specific event like the loss of a loved one.
C: Hypoxia of the brain - Hypoxia would likely present with more acute symptoms and physical signs, such as shortness of breath or cyanosis.
D: Delirium from medications - Delirium is characterized by acute onset and fluctuating course, often related to medication changes or other medical conditions, rather than an emotional trigger like grief.

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