Nokea
A 72-year-old female patient has the medical diagnosis of delirium secondary to anticholinergic medication toxicity. A nurse planning discharge care must consider the need to teach the family to be alert for maladaptive cognitive symptoms because:
- A. delirium is a hypersensitivity reaction.
- B. the elderly often deny changes in cognition.
- C. elderly females are more prone to delirium than elderly males.
- D. slower metabolism in the elderly predisposes to medication toxicity.
Correct Answer: D
Rationale: The correct answer is D because slower metabolism in the elderly can lead to medication toxicity, including anticholinergic toxicity causing delirium. As people age, their metabolism slows down, making them more susceptible to drug accumulation and toxicity. This can result in cognitive symptoms like delirium.
A: Delirium is not a hypersensitivity reaction; it is an acute state of confusion.
B: Denial of cognitive changes is not directly related to the risk of medication toxicity in the elderly.
C: Gender is not a significant factor in medication toxicity leading to delirium; it is more related to individual metabolism and drug interactions.
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A 34-year-old client with residual schizophrenia frequently displays ambivalence. The community mental health nurse suggests that a realistic short-term outcome for this client problem is that client will:
- A. Decide his or her own daily schedule
- B. Refuse to attend activities
- C. Choose which clinic staff member to work with
- D. Choose between two outfits to wear each morning
Correct Answer: D
Rationale: The correct answer is D: Choose between two outfits to wear each morning. This outcome is realistic because it focuses on a concrete and manageable task that the client can achieve, promoting independence and decision-making skills. It also addresses the issue of ambivalence by providing the client with limited choices, which can help reduce anxiety and facilitate decision-making.
A: Decide his or her own daily schedule - This option may be too overwhelming for a client with residual schizophrenia and may not directly address the issue of ambivalence.
B: Refuse to attend activities - This option is negative and does not promote progress or independence for the client.
C: Choose which clinic staff member to work with - This option may not be directly related to the client's ambivalence or daily functioning, making it less relevant as a short-term goal.
Which point should be included in teaching patients and families about relapse?
- A. Patients who relapse are those who have failed to take their medications.
- B. Caffeine and nicotine can reduce the effectiveness of antipsychotic drugs.
- C. With support, education, and adherence to treatment, patients will not relapse.
- D. Posthospitalization education about medication side effects is usually ineffective.
Correct Answer: B
Rationale: Step-by-step rationale for why answer B is correct:
1. Caffeine and nicotine are known to reduce the effectiveness of antipsychotic drugs.
2. Teaching patients and families about this can help them understand the importance of avoiding these substances.
3. By avoiding caffeine and nicotine, patients can improve the effectiveness of their treatment and reduce the risk of relapse.
4. This information empowers patients and families to make informed decisions to support treatment outcomes.
Summary of why other choices are incorrect:
A: Incorrect because relapse can occur due to various factors, not just medication non-adherence.
C: Incorrect because relapse is a complex issue that may not be entirely prevented even with support, education, and adherence.
D: Incorrect because education about medication side effects is still valuable, even if it may not entirely prevent relapse.
After 5 years in a state hospital, an adult diagnosed with schizophrenia was discharged to the community. This patient now requires persistent direction to accomplish activities of daily living and expects others to provide meals and do laundry. The nurse assesses this behavior as the probable result of:
- A. side effects of antipsychotic medications.
- B. dependency caused by institutionalization.
- C. cognitive deterioration from schizophrenia.
- D. stress associated with acclimation to the community.
Correct Answer: B
Rationale: Institutions impede independent functioning, fostering dependency (B) over time as daily activities are directed by staff. Antipsychotic side effects (A) and cognitive issues (C) may contribute, but the scenario suggests institutional adaptation. Stress (D) is less likely the primary cause.
The nurse is assessing a patient with anorexia nervosa. What is the most important physical examination finding to monitor?
- A. Blood pressure and heart rate.
- B. Height and weight changes.
- C. Skin turgor and hydration status.
- D. Respiratory rate and lung function.
Correct Answer: B
Rationale: The correct answer is B: Height and weight changes. In anorexia nervosa, monitoring height and weight changes is crucial as it reflects the patient's nutritional status and overall health. Weight loss and changes in height can indicate severe malnutrition and potential complications. Blood pressure and heart rate (choice A) can be affected by various factors in anorexia nervosa but may not directly reflect the patient's nutritional status. Skin turgor and hydration status (choice C) are important indicators of hydration levels but may not provide a comprehensive assessment of the patient's nutritional status. Respiratory rate and lung function (choice D) are important, but they may not be the most critical physical examination findings to monitor in anorexia nervosa.
During an initial patient interview, the psychiatric-mental health nurse begins by asking the patient to describe their:
- A. current situation
- B. feelings about the current situation
- C. personal history
- D. thoughts about the current situation
Correct Answer: A
Rationale: Starting with the current situation provides a concrete entry point to assess the patient's immediate needs and context.