Nokea
A catatonic patient admitted in a stuporous condition begins to demonstrate increased motor activity. During his assessment, the psychiatrist raises the patient's arm above his head and releases it. The patient maintains the position his arm was placed in, immobile in that position for 15 minutes, moving only when the nurse gently lowers his arm. What symptom is demonstrated by this assessment technique?
- A. Echopraxia
- B. Waxy flexibility
- C. Depersonalization
- D. Thought withdrawal
Correct Answer: B
Rationale: The correct answer is B: Waxy flexibility. This symptom is demonstrated by the patient's ability to maintain the position his arm was placed in, immobile, for an extended period of time. This is characteristic of catatonia, where individuals exhibit increased motor activity and abnormal posturing. Waxy flexibility refers to the tendency of catatonic patients to maintain positions that they are placed in by others, almost as if their limbs are made of wax and can be molded into different positions.
Explanation for other choices:
A: Echopraxia involves mimicking the movements of others, which is not demonstrated in this scenario.
C: Depersonalization refers to feeling detached from oneself, which is not evident in the patient's behavior during the assessment.
D: Thought withdrawal is a symptom of schizophrenia where thoughts are believed to be removed from one's mind by an external force, which is not relevant to the patient's motor behavior in this case.
You may also like to solve these questions
A woman who is a victim of severe emotional violence tells the nurse that her husband abuses her most often when he is intoxicated, just as his father had beaten him and his mother. The woman is aware of the location of a safe house and has considered leaving home with her two children, but she cites being brought up to believe 'you keep quiet and stay together, no matter what happens.' She states the husband is always apologetic and remorseful after an incident. The nurse responds, 'You cannot live like this; you have to defend yourself and your children.' Which statement most accurately describes the nurse's response?
- A. It is an honest and direct response that will help build trust and rapport.
- B. It suggests that the nurse herself has been a victim of physical abuse.
- C. It is unprofessional, but it will likely help by motivating the patient.
- D. It is a human but unprofessional response and is not helpful.
Correct Answer: D
Rationale: The correct answer is D because the nurse's response is not helpful. Here's a step-by-step rationale:
1. The nurse's response is human because she empathizes with the woman's situation.
2. However, the response is unprofessional as it is too directive and lacks a proper assessment or exploration of the woman's feelings and options.
3. Telling the woman to defend herself may put her at further risk and does not address the underlying issues of abuse and trauma.
4. The response fails to consider the complexities of the woman's situation, such as her cultural beliefs and the cycle of violence she is caught in.
5. Instead, a professional response would involve a more holistic approach, including safety planning, providing resources, and offering support without judgment or pressure.
An adult experienced a myocardial infarction six months ago. At a follow-up visit, this adult says, 'I haven't had much interest in sex since my heart attack. I finished my rehabilitation program, but having sex strains my heart. I don't know if my heart is strong enough.' Which nursing diagnosis applies?
- A. Deficient knowledge related to faulty perception of health status
- B. Disturbed self-concept related to required lifestyle changes
- C. Disturbed body image related to treatment side effects
- D. Sexual dysfunction related to self-esteem disturbance
Correct Answer: A
Rationale: The correct answer is A: Deficient knowledge related to faulty perception of health status. The patient's statement indicates a lack of understanding about their health status and the impact of their myocardial infarction on their sexual activity. The patient is attributing their decreased interest in sex to a fear of straining their heart, indicating a faulty perception of their health status. This nursing diagnosis addresses the patient's need for education and clarification about their condition to alleviate their concerns and improve their confidence in engaging in sexual activity safely.
Choices B, C, and D are incorrect because they do not directly address the patient's lack of knowledge and faulty perception about their health status. Disturbed self-concept (B) relates more to how the patient perceives themselves due to lifestyle changes, while disturbed body image (C) pertains to physical appearance changes. Sexual dysfunction (D) is related to difficulties in sexual function, which is not the primary issue in this scenario.
A patient with schizophrenia is admitted to the psychiatric unit in an acutely disturbed, violent state. He is given several doses of haloperidol (Haldol) and becomes calm and approachable. During rounds the nurse notices the patient has his head rotated to one side in a stiffly fixed position. His lower jaw is thrust forward and he appears severely anxious. The patient has _____, and the nurse should _____.
- A. A dystonic reaction"¦administer PRN IM benztropine (Cogentin)
- B. Tardive dyskinesia"¦seek a change in the drug or its dosage
- C. Waxy flexibility"¦continue treatment with antipsychotic drugs
- D. Akathisia"¦administer PRN diphenhydramine (Benadryl) PO
Correct Answer: A
Rationale: The correct answer is A: A dystonic reaction"¦administer PRN IM benztropine (Cogentin). This patient is exhibiting symptoms of acute dystonia, a extrapyramidal side effect of haloperidol. Dystonic reactions are characterized by sustained muscle contractions causing abnormal postures. Benztropine is an anticholinergic medication that helps alleviate these symptoms by blocking the neurotransmitter acetylcholine. Administering benztropine is the appropriate treatment for acute dystonia.
Summary of other choices:
B: Tardive dyskinesia"¦seek a change in the drug or its dosage - Tardive dyskinesia is a side effect that occurs after long-term antipsychotic use, not acutely like in this case.
C: Waxy flexibility"¦continue treatment with antipsychotic drugs - Waxy flexibility is a symptom of catatonia, not a side effect of antipsychotic medications
The head nurse on a unit that serves persons with cognitive impairment is concerned about her staff, many of whom seem to be becoming 'burned out' by their challenging work. Which response by the head nurse is most likely to minimize staff frustration and burnout on the unit? Select all that apply.
- A. Educate staff regarding realistic expectations for this patient population.
- B. Arrange for 12-hour shifts so that staff can have more days off per week.
- C. Guide staff to use small, realistic goals as their measure of patient progress.
- D. None of the above.
Correct Answer: A
Rationale: The correct answer is A because educating staff about realistic expectations for working with persons with cognitive impairment can help them understand the challenges they may face and develop appropriate coping strategies. This knowledge can reduce frustration and burnout by promoting a better understanding of the patients' needs and behaviors.
Choice B, arranging for 12-hour shifts, may actually increase staff burnout as longer shifts can be physically and mentally taxing. Choice C, guiding staff to use small, realistic goals, while helpful in patient care, may not directly address staff burnout. Therefore, the most effective approach to minimize staff frustration and burnout in this scenario is education on realistic expectations.
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.