Nokea
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.' The client has remained delusional since admission. An initial expected outcome would be that the client will:
- A. Allow the nurse to logically dispute the delusion
- B. Distinguish external boundaries
- C. Engage in reality-oriented conversation
- D. Explain why she thinks she is the 'Queen of Hearts'
Correct Answer: C
Rationale: The correct answer is C: Engage in reality-oriented conversation. This is the most appropriate initial expected outcome because it focuses on helping the client ground herself in reality. Engaging in reality-oriented conversation can help the client understand and acknowledge her delusions, leading to potential insight and eventual treatment.
A: Allowing the nurse to logically dispute the delusion may not be effective initially as the client may not be receptive to this approach during the acute phase of her delusion.
B: Distinguishing external boundaries may not address the underlying delusional beliefs and may not be the most immediate concern.
D: Explaining why she thinks she is the 'Queen of Hearts' may reinforce the delusion rather than challenging it.
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Asking the husband to leave is likely to increase the client's anxiety and alter test results. Testing in the more familiar, comfortable surroundings of the home will yield more reliable results.
- A. Asking the husband to leave is likely to increase the client's anxiety and alter test results because the presence of a loved one can provide comfort and support during a potentially stressful situation.
- B. Testing in the more familiar, comfortable surroundings of the home will yield more reliable results because the client is in a setting where they feel safe and secure, which can help reduce anxiety and promote accurate test outcomes.
- C. Both A and B.
- D. None of the above.
Correct Answer: C
Rationale: The correct answer is C because both statements A and B provide valid reasons supported by psychological principles. Statement A is correct as the presence of a loved one can indeed provide comfort and support, reducing anxiety and potentially improving test outcomes. Statement B is also accurate as testing in familiar surroundings can help the client feel safe and secure, leading to more reliable results. Therefore, combining these two factors - the presence of a loved one and testing in a comfortable environment - would likely yield the most reliable results by addressing both emotional and environmental factors impacting the client's anxiety levels during the test.
A patient with the diagnosis of schizophrenia, disorganized type, approaches the nurse and says, "It's beat, it's eat. No room for doom." The nurse can correctly assess this verbalization as:
- A. Neologisms
- B. Clanging
- C. Ideas of reference.
- D. Associative looseness.
Correct Answer: B
Rationale: The correct answer is B: Clanging. Clanging refers to the association of words based on sound rather than meaning. In this case, the patient's verbalization "It's beat, it's eat. No room for doom" demonstrates a pattern of words that rhyme or have similar sounds but lack coherent meaning. This is characteristic of clanging seen in disorganized schizophrenia. Neologisms (A) are newly created words with unique meanings, which is not evident here. Ideas of reference (C) involve misinterpreting unrelated events as being personally significant, which is not demonstrated in the patient's statement. Associative looseness (D) is a thought disorder where ideas are loosely associated, but the patient's statement does not show this specific feature.
A nurse is working with a patient with bulimia nervosa. Which outcome would indicate successful intervention?
- A. The patient eats three full meals daily without purging.
- B. The patient agrees to begin psychotherapy without resistance.
- C. The patient loses 5% of their body weight over 3 months.
- D. The patient expresses improved body image but still purges occasionally.
Correct Answer: A
Rationale: The correct answer is A because it indicates successful intervention in bulimia nervosa by demonstrating healthy eating behavior without purging. This outcome reflects improved control over binge-purge cycles and supports physical health. Choices B and D show progress but do not directly address the core issue of purging behavior. Choice C, losing weight, can be a misleading indicator and may not necessarily reflect improved psychological and behavioral outcomes associated with recovery from bulimia nervosa.
A child, age 5, was admitted to the children's unit, having been sexually abused by an acquaintance of her family. The child refuses to talk and participate in unit activities, choosing to stay in her room with her stuffed animals. Which therapeutic intervention will best help the child release pent-up feelings about the abuse?
- A. Individual communication with the nurse
- B. Play therapy
- C. Family therapy
- D. Role-play with other children on the unit
Correct Answer: B
Rationale: The correct answer is B: Play therapy. Play therapy is the most suitable therapeutic intervention for a child in this scenario because it allows the child to express their feelings and experiences through play, which is a natural form of communication for children. Through play therapy, the child can act out their experiences using toys and create a safe space to process their emotions without having to verbally communicate. It helps the child release pent-up feelings and trauma in a non-threatening environment.
Summary of other choices:
A: Individual communication with the nurse may not be as effective as play therapy in this case as the child is not yet comfortable verbalizing their feelings.
C: Family therapy may not be appropriate at this stage as the child is not ready to engage with family members about the abuse.
D: Role-play with other children on the unit may not be beneficial as it can potentially trigger more anxiety and discomfort for the abused child.
What is the most important aspect of refeeding for a patient with anorexia nervosa?
- A. Refeeding should begin slowly to avoid complications.
- B. Rapid weight gain is essential to restore health.
- C. The patient should be encouraged to make independent food choices.
- D. Fluid intake should be restricted to avoid water retention.
Correct Answer: A
Rationale: The correct answer is A because refeeding should start slowly to prevent refeeding syndrome, a potentially life-threatening condition caused by rapid electrolyte shifts. Gradually increasing caloric intake allows the body to adjust and reduces the risk of complications. Rapid weight gain (B) is not recommended as it can lead to medical complications. Encouraging independent food choices (C) may not be suitable initially as structured meal plans are often necessary. Restricting fluid intake (D) is not advisable as adequate hydration is crucial during refeeding.