Age Specific Nursing 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 nursing diagnosis is "Disturbed thought processes" (C) because the client's behavior of being delusional, shouting obscenities, and demonstrating loosely associated thoughts indicates a disruption in their ability to think clearly and logically. This diagnosis reflects the client's cognitive dysfunction and disorganized thinking patterns.

Choice A (Risk for violence) is incorrect because the client's behavior does not directly suggest a risk for violence towards others or themselves.

Choice B (Defensive coping) is incorrect as the client's behavior is not indicative of using defensive mechanisms to cope with stress or anxiety.

Choice D (Impaired memory) is incorrect as the client's symptoms are more indicative of thought processing issues rather than memory deficits.

In summary, the client's presentation aligns closely with symptoms of disturbed thought processes, making it the most appropriate nursing diagnosis in this case.

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A patient states that unit staff members have been avoiding them since an attempt to self-mutilate. The psychiatric-mental health nurse's most appropriate response is to:

  • A. apologize for the staff's behavior
  • B. explain that feelings of rejection are typical after self-mutilation
  • C. listen, redirect the patient to their feelings, and explore the issue with the staff
  • D. report the matter to the nurse manager
Correct Answer: C

Rationale: Listening validates the patient, redirecting focuses on their emotions, and exploring with staff addresses care quality.

The intervention that would be most appropriate of a male client develops orthostatic hypotension while taking amitriptyline (Elavil) is

  • A. Consulting with the physician about substituting a different type of antidepressant
  • B. Advising the client to sit up for 1 minute before getting out of bed
  • C. Instructing the client to double the dosage until the problem resolves.
  • D. Instruct the client to stop medication immediately
Correct Answer: B

Rationale: Advising the client to sit up slowly helps manage orthostatic hypotension, a common side effect of amitriptyline, by preventing sudden drops in blood pressure.

It is a primary dementia that is incurable, irreversible, and fatal. It is caused by the accumulation of amyloid protein in the neurons, resulting in senile plaques.

  • A. Alzheimer's disease.
  • B. Frontotemporal dementia.
  • C. Parkinson's disease dementia.
  • D. None of the above.
Correct Answer: A

Rationale: The correct answer is A: Alzheimer's disease. Alzheimer's disease is a primary dementia that is characterized by the accumulation of amyloid protein in neurons, leading to senile plaques. It is incurable, irreversible, and fatal. Frontotemporal dementia (B) is caused by the degeneration of frontal and temporal lobes, not amyloid protein accumulation. Parkinson's disease dementia (C) is a secondary dementia that occurs as a complication of Parkinson's disease, not due to amyloid protein accumulation. Choice D is incorrect as Alzheimer's disease fits all the criteria mentioned in the question.

The nurse is administering haloperidol (Haldol) to a client experiencing delusions and hallucinations associated with schizophrenia. The nurse can expect symptom abatement as a result of the drug's action to:

  • A. Reduce the number of brain cells that crave dopamine
  • B. Block dopamine receptors, making dopamine less available
  • C. Enhance dopamine receptors, making more dopamine available
  • D. Cause increased cellular production of dopamine
Correct Answer: B

Rationale: The correct answer is B because haloperidol is a typical antipsychotic that works by blocking dopamine receptors in the brain. By blocking these receptors, haloperidol reduces the effects of excess dopamine, which is known to contribute to symptoms of schizophrenia such as delusions and hallucinations. This action helps alleviate the positive symptoms of schizophrenia.

Choice A is incorrect because haloperidol does not reduce the number of brain cells that crave dopamine; it acts on the receptors themselves. Choice C is incorrect because enhancing dopamine receptors would lead to an increase in the effects of dopamine, worsening symptoms. Choice D is incorrect because haloperidol does not cause increased cellular production of dopamine; it blocks dopamine receptors instead.

A person who is the caregiver of a parent with early-to-middle-stage Alzheimer disease is concerned about possible episodes of incontinence. What strategy should the nurse suggest?

  • A. Limiting the patient's fluid intake to 1000 ml daily
  • B. Discussing the use of an indwelling catheter with the physician
  • C. Putting plastic coverings on the beds, upholstered chairs, and sofas
  • D. Taking the patient to the bathroom at least every 2 hours when the patient is awake
Correct Answer: D

Rationale: The correct answer is D: Taking the patient to the bathroom at least every 2 hours when the patient is awake. This strategy helps prevent episodes of incontinence by ensuring the patient has regular opportunities to void. It promotes continence through scheduled toileting, maintaining the patient's dignity and preventing accidents.

Choice A is incorrect as restricting fluid intake can lead to dehydration and other health issues. Choice B is incorrect because indwelling catheters are not recommended for managing incontinence in Alzheimer's patients due to the risk of urinary tract infections. Choice C is incorrect as it only addresses the aftermath of incontinence, not the prevention of it.

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