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A 35-year-old woman who is being interviewed by the advanced practice nurse indicates that she has few friends, fears criticism from others, and withholds information about her thoughts and feelings because she anticipates a negative reaction. Based on these data, the nurse suspects that Sarah may later be diagnosed as having:
- A. Borderline personality disorder
- B. Histrionic personality disorder
- C. Avoidant personality disorder
- D. Schizoid personality disorder
Correct Answer: C
Rationale: The correct answer is C: Avoidant personality disorder. This is because the woman's fear of criticism, avoidance of sharing thoughts/feelings, and limited social circle are indicative of social inhibition and feelings of inadequacy, which are key features of avoidant personality disorder.
A: Borderline personality disorder is characterized by unstable relationships, self-image, and emotions, as well as impulsivity and fear of abandonment.
B: Histrionic personality disorder involves attention-seeking behavior, emotions that are shallow and rapidly shifting, and the need to be the center of attention.
D: Schizoid personality disorder is marked by social detachment, limited emotional expression, and preference for solitary activities.
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A 91-year-old female client with dementia is being seen by the home health nurse. Both she and her husband, who is 92 years old, were very active until her dementia became debilitating. Since that time, the client does not recognize her husband or children, forgets how to eat and dress, and wanders about the house day and night. Her husband wants to keep her at home to care for her, but the nurse notices that he is increasingly tired with each visit. What is the nurse's priority intervention for the nursing diagnosis of caregiver role strain?
- A. Discuss strategies to coordinate care and other responsibilities
- B. Encourage involvement in support groups
- C. Identify resources to include financial, legal, and respite care
- D. Stress the importance of self-nurturing
Correct Answer: A
Rationale: The correct answer is A: Discuss strategies to coordinate care and other responsibilities. The priority intervention for caregiver role strain is to help the husband effectively manage caring for his wife with dementia. By discussing strategies to coordinate care and other responsibilities, the nurse can assist the husband in creating a plan to ensure the client's needs are met while also addressing his own well-being. This intervention will help alleviate the husband's increasing tiredness and provide support in managing the caregiving responsibilities.
Summary of other choices:
B: Encourage involvement in support groups - While support groups can be beneficial, the immediate priority is to address the husband's caregiving responsibilities.
C: Identify resources to include financial, legal, and respite care - While important, these resources may not directly address the husband's current strain in caring for his wife.
D: Stress the importance of self-nurturing - While self-care is important, the immediate focus should be on assisting the husband in managing his caregiving responsibilities.
The main focus of medical management for anorexia is to:
- A. Encourage rapid weight gain.
- B. Encourage the client to eat voluntarily.
- C. Teach more appropriate food choices.
- D. None of the above.
Correct Answer: D
Rationale: The correct answer is D because the main focus of medical management for anorexia is not to encourage rapid weight gain, as it can lead to serious health complications. Encouraging the client to eat voluntarily is also not the main focus, as anorexia involves psychological factors that go beyond simple lack of appetite. Teaching more appropriate food choices is not the main focus either, as anorexia requires comprehensive treatment that addresses underlying emotional issues. Overall, the main focus is on a multidisciplinary approach that includes therapy, nutritional counseling, and medical monitoring to address the physical and psychological aspects of the disorder.
The wife of a client newly diagnosed with paranoid schizophrenia asks the nurse, 'My husband was well adjusted until a month ago, and then, after a lot of work stress, he got sick. What can I expect? Will he be this sick for the rest of his life?' What information can the nurse provide about prognosis?
- A. This disorder responds well to treatment and, with follow-up, may not recur.'
- B. All types of schizophrenia are chronic relapsing disorders.'
- C. Outcomes are poor related to client prehospital disorganization.'
- D. The usual outcome is that only partial remission is achieved.'
Correct Answer: A
Rationale: The correct answer is A: "This disorder responds well to treatment and, with follow-up, may not recur."
Rationale:
1. Paranoid schizophrenia typically responds well to treatment, especially with early intervention.
2. With proper medication and therapy, individuals with paranoid schizophrenia can experience significant improvement and lead fulfilling lives.
3. Follow-up care and support are crucial in maintaining stability and preventing relapses.
Summary of why other choices are incorrect:
B: All types of schizophrenia are chronic relapsing disorders - This is not accurate as outcomes can vary depending on the subtype of schizophrenia.
C: Outcomes are poor related to client prehospital disorganization - This statement is too general and does not specifically address the prognosis of paranoid schizophrenia.
D: The usual outcome is that only partial remission is achieved - This is not always the case, as many individuals with paranoid schizophrenia can achieve full remission with appropriate treatment.
The family of a patient with schizophrenia who has been stable for a year reports to the community mental health nurse that the patient reports feeling tense and having difficulty concentrating. He sleeps only 3 to 4 hours nightly and has begun to talk about creatures called 'volmers' hiding in the warehouse where he works and undoing his work each night. This information most likely suggests:
- A. medication nonadherence.
- B. a need for psychoeducation.
- C. the chronic nature of his illness.
- D. relapse of his schizophrenia.
Correct Answer: D
Rationale: The correct answer is D: relapse of his schizophrenia. The patient is displaying symptoms such as feeling tense, difficulty concentrating, disturbed sleep, and delusional thoughts about creatures hiding in his workplace. These symptoms indicate a return of psychotic features characteristic of schizophrenia, suggesting a relapse. This is supported by the patient's history of schizophrenia and the sudden onset of symptoms after a period of stability. Medication nonadherence (choice A) could be a possible cause, but the patient's symptoms are more indicative of a relapse. While psychoeducation (choice B) is important, the patient's current symptoms require immediate attention for relapse management. The chronic nature of his illness (choice C) is a general characteristic of schizophrenia and does not explain the current symptoms.
The nurse has been working with a patient diagnosed with schizophrenia who experiences auditory hallucinations. The patient relates, 'When I first heard the voices they said nice things about me. Lately, they've changed and they say bad things.' What information has the least impact on therapeutic patient care at this point in the hospitalization?
- A. Do you trust me to help you with the voices?'
- B. Are the voices commanding you to do something?'
- C. How often during 24 hours do you hear the voices?'
- D. Do you hear the voices if you're busy in noisy environment?'
Correct Answer: A
Rationale: Rationale for Correct Answer (A): Asking the patient if they trust the nurse to help with the voices is the least impactful at this point because establishing trust should have already been a priority earlier in the hospitalization. The focus now should be on assessing the nature and frequency of the auditory hallucinations to guide further treatment and intervention.
Summary of Incorrect Choices:
B: This question is important to assess if the voices are commanding potentially harmful actions.
C: Understanding the frequency of the voices is crucial in evaluating the severity of the symptoms.
D: Inquiring about hearing voices in different environments helps assess the impact of external factors on the hallucinations.