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A 34-year-old male admitted with catatonic schizophrenia has been mute and motionless for several days while at home prior to admission. He still appears stuporous in the hospital. Which nursing intervention would be an initial priority?
- A. Orienting the client to the unit
- B. Assessing the client for physical problems
- C. Establishing a nonthreatening relationship
- D. Reinforcing reality with the client
Correct Answer: B
Rationale: The correct answer is B: Assessing the client for physical problems. This is the initial priority because the client's muteness and motionless state could be due to an underlying physical issue that needs immediate attention, such as dehydration, malnutrition, or infection. By assessing for physical problems first, the nurse can rule out any urgent medical concerns before addressing the client's mental health needs.
A: Orienting the client to the unit - While important, this can be done after addressing any physical problems.
C: Establishing a nonthreatening relationship - Also essential, but assessing physical health takes precedence.
D: Reinforcing reality with the client - Not the immediate priority; physical assessment should come first.
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Which is the most appropriate initial goal for a nurse when attempting to overcome personal negative attitudes about a patient who has a history of returning to an abusive spouse?
- A. Exploring own attitudes and values toward survivors of violence
- B. Identifying the dysfunctional behaviors exhibited by the violent family
- C. Concentrating on identifying any possible personal abusive relationships
- D. Attending seminars on the psychological impact of being the victim of abuse
Correct Answer: A
Rationale: The correct answer is A because exploring one's own attitudes and values towards survivors of violence is crucial in overcoming personal negative attitudes. By reflecting on personal biases, the nurse can gain self-awareness and empathy, enabling better care for the patient. Choice B is incorrect as it focuses on the abuser's behaviors, not the nurse's attitudes. Choice C is incorrect as it shifts the focus to the nurse's personal relationships. Choice D is incorrect as attending seminars does not directly address the nurse's personal attitudes.
A history reveals that a patient virtually stopped eating 5 months ago and lost 25% of body weight. The nurse says, "Describe what you think about your present weight and how you look."Â Which response would be most consistent with anorexia nervosa?
- A. "I'm fat and ugly."Â
- B. "What I think about myself is my business."Â
- C. "I'm grossly underweight, but I cover it well."Â
- D. "I'm a few pounds overweight, but I can live with it."Â
Correct Answer: A
Rationale: The correct answer is A because the response indicates a distorted body image, a common characteristic of anorexia nervosa. Anorexia nervosa is characterized by an intense fear of gaining weight and a distorted perception of body image, leading individuals to see themselves as overweight despite being underweight. In this case, the patient's response of "I'm fat and ugly" demonstrates a negative perception of their weight and appearance, which aligns with the distorted body image seen in anorexia nervosa.
Choices B, C, and D are incorrect:
B: "What I think about myself is my business" - This response does not indicate a distorted body image or negative perception of weight and appearance, which are key features of anorexia nervosa.
C: "I'm grossly underweight, but I cover it well" - While this response acknowledges being underweight, it does not reflect the distorted body image commonly seen in anorexia nervosa.
D: "I'm a
A widow, aged 72 years, lives alone and is visited weekly by her son. She takes digoxin, hydrochlorothiazide, and an antihypertensive drug. She also has a prescription for diazepam (Valium) as needed for moderate to severe anxiety. When the son visited today, he found his mother confused and disoriented, with an unsteady gait. The nurse assessed the patient as having several cognitive problems, including memory and attention deficits and fluctuating levels of orientation. The nurse confirms that the patient's symptoms developed:
- A. Over the past few days.
- B. Over the past few weeks.
- C. Over the past few months.
- D. None of the above.
Correct Answer: A
Rationale: The correct answer is A: Over the past few days. The sudden onset of confusion, disorientation, and cognitive deficits in the elderly patient suggests an acute change in her condition. This acute change is more indicative of a recent event or medication-related issue rather than a gradual decline over weeks or months. The sudden onset could be due to factors such as medication interactions, overdose, or underlying medical conditions. It is crucial to investigate recent changes in medications, lab results, or any other potential triggers that might have led to this acute cognitive decline. Choices B, C, and D are incorrect because they imply a gradual decline over weeks, months, or no specific timeframe, which does not align with the sudden onset observed in the patient.
A nurse assesses that which of the following individuals is most likely to engage in eating behaviors characteristic of bulimia?
- A. A person who weighs 225 pounds and is 5 feet 4 inches tall.
- B. A person who is 5 pounds overweight and cannot stick to a diet.
- C. A person who lost up to 40 pounds but gained it back within 1 year.
- D. None of the above.
Correct Answer: A
Rationale: Step 1: Individuals with bulimia often engage in episodes of binge eating followed by purging behaviors.
Step 2: Choice A, a person who is significantly overweight, is more likely to engage in binge eating behavior.
Step 3: Being overweight can be a risk factor for bulimia due to body image concerns.
Step 4: Choices B and C do not provide as strong indicators for bulimia as choice A.
Summary: Choice A is correct as being significantly overweight is a common characteristic of individuals with bulimia. Choices B and C lack the same level of risk factors for engaging in eating behaviors characteristic of bulimia.
An appropriate short-term goal for a withdrawn, isolated patient diagnosed with schizophrenia is:
- A. The patient will participate in all therapeutic activities.'
- B. The patient will define major barriers to communication.'
- C. The patient will talk about feelings of withdrawal in group.'
- D. The patient will consistently interact with an assigned nurse.'
Correct Answer: D
Rationale: Step 1: Interacting with an assigned nurse helps build a therapeutic relationship, essential for engaging withdrawn patients.
Step 2: Consistent interaction promotes trust and communication, aiding in the patient's socialization.
Step 3: This goal is specific, measurable, achievable, relevant, and time-bound, aligning with the SMART criteria.
Summary:
A: Participation in all activities may overwhelm the patient.
B: Defining barriers to communication is too advanced for someone withdrawn.
C: Talking about feelings in a group setting may be too challenging for a withdrawn patient.