Nokea
A 72-year-old patient has the medical diagnosis of delirium secondary to anticholinergic medication toxicity. Family members are very anxious and express their concerns about placing the patient in a nursing home. What information should serve as a basis for the nurse's reply?
- A. Delirium is reversible, and the patient will likely recover.
- B. The symptoms are related to depression, which can be treated.
- C. Delirium usually progresses to dementia, which is usually permanent.
- D. Home care should be attempted; a nursing home should be the last resort.
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. Delirium is an acute, reversible condition caused by underlying factors like medication toxicity.
2. By addressing the anticholinergic medication toxicity, the delirium can be resolved, leading to recovery.
3. The patient's age does not necessarily indicate a progression to dementia.
4. Placing the patient in a nursing home is not the immediate solution; resolving the toxicity should be the priority.
Summary:
Choice A is correct because delirium is reversible with appropriate treatment. Choices B, C, and D are incorrect because they do not address the underlying cause of delirium or provide accurate information about its progression or management.
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A patient who has been physically abused says, 'When I called the police, I just wanted my spouse to stop shoving me around and kicking me. I didn't want anyone to get in trouble. It's easy to get angry with me because I spend too much money.' Which nursing intervention would be most therapeutic for this patient?
- A. You feel your spouse was justified in the abuse because you overspent?'
- B. Tell your spouse that if this happens again, I'll report it to the police.'
- C. Your spouse abuses you when you overspend. So you think it will stop if you stop spending money?'
- D. I can understand that you don't want to press charges, but your spouse needs help controlling anger.'
Correct Answer: A
Rationale: The correct answer is A because it focuses on therapeutic communication by reflecting the patient's feelings and thoughts back to them without judgment. By repeating the patient's words, the nurse shows empathy and understanding, which can help build trust and rapport. Choices B and D may escalate the situation and go against the patient's wishes, potentially causing further harm. Choice C assumes a causal relationship between overspending and abuse, which is not appropriate and may blame the victim. Overall, choice A promotes a non-judgmental and supportive environment, which is crucial in addressing issues of abuse.
After assessing a patient with anorexia nervosa, a nurse writes the following nursing diagnosis: imbalanced nutrition, less than body requirements related to refusal to eat as evidenced by being 25% below body weight for height. The expected outcome should be listed as:
- A. Patient will identify cognitive distortions about food, weight, and body shape.'
- B. Patient will exhibit fewer signs of malnutrition within 2 weeks of hospitalization.'
- C. Patient will be able to describe both the physical and emotional complications of the eating disorder.'
- D. Patient will restore healthy eating patterns and normalize physiological parameters related to weight and nutrition.'
Correct Answer: D
Rationale: The correct answer is D because the expected outcome for a patient with imbalanced nutrition due to anorexia nervosa should focus on restoring healthy eating patterns and normalizing physiological parameters related to weight and nutrition. This outcome directly addresses the underlying issue of inadequate nutrition intake and helps the patient achieve a healthier state.
A: While identifying cognitive distortions is important for addressing the psychological aspects of anorexia nervosa, it does not directly address the patient's nutritional needs.
B: Exhibiting fewer signs of malnutrition is a vague outcome and does not specify how the patient will achieve this improvement.
C: Describing physical and emotional complications is informative but does not address the primary goal of improving nutrition intake and weight restoration.
A patient asks, 'What advantage does a durable power of attorney for health care have over a living will?' The nurse should reply, 'A durable power of attorney for health care:
- A. gives your agent authority to make decisions during any illness if you are incapacitated
- B. can be given only to a relative, usually the next of kin, who has your best interests at heart
- C. can be used only if you have a terminal illness and become incapacitated
- D. cannot be implemented until 30 days after the documents are signed
Correct Answer: A
Rationale: A durable power of attorney for health care is an instrument that appoints a person other than a health care provider to act as an individuals agent in the event that he or she is unable to make medical decisions. No waiting period is required for it to become effective, and the individual does not have to be terminally ill or incompetent for the person appointed to act on the individuals behalf.
A psychiatric technician asks the nurse to explain the difference between schizotypal personality disorder and schizophrenia. The information that should serve as the basis for the nurse's response is the fact that with schizotypal personality disorder:
- A. There is greater personality disorganization than in schizophrenia
- B. There may be misinterpretation of events but not psychosis
- C. The client will be sicker and require longer hospitalization
- D. The client will be more outgoing, actively seeking interactions with others
Correct Answer: B
Rationale: The correct answer is B: There may be misinterpretation of events but not psychosis. In schizotypal personality disorder, individuals may have odd beliefs, behaviors, and experiences, leading to misinterpretation of events, but they do not typically experience full-blown psychosis as seen in schizophrenia. This is a key distinction between the two disorders. Choice A is incorrect because schizophrenia is characterized by more severe disorganization of thoughts and behaviors. Choice C is incorrect as individuals with schizotypal personality disorder typically do not require long hospitalizations compared to those with schizophrenia. Choice D is incorrect as individuals with schizotypal personality disorder tend to be more socially isolated and have difficulty forming close relationships.
An outpatient diagnosed with schizophrenia tells the nurse, I am here to save the world. I threw away the pills because they make God go away. The nurse identifies the patients reason for medication nonadherence as:
- A. poor alliance with clinicians.
- B. inadequate discharge planning.
- C. dislike of medication side effects.
- D. lack of insight associated with the illness.
Correct Answer: D
Rationale: The patient's belief in an exalted role and rejection of medication due to hallucinations (God's voice) reflect lack of insight (D) into their illness, the primary reason for nonadherence here.