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A client, age 70, was brought into the Emergency Department by family members who reported a fall. During the assessment, the nurse became suspicious that the client had suffered physical abuse. The client denied that she had been abused. Her denial is most likely based on her:
- A. Fear of retaliation.
- B. Emotional response to the situation.
- C. Cognitive impairment.
- D. None of the above.
Correct Answer: B
Rationale: The correct answer is B: Emotional response to the situation. The client's denial is likely due to emotional factors such as shame, embarrassment, or fear of causing trouble for family members. This emotional response can lead the client to deny abuse even when it has occurred. Choice A is incorrect because fear of retaliation may be a factor, but emotional response is more likely. Choice C is incorrect as cognitive impairment would affect the client's ability to understand and respond to the situation, not necessarily lead to denial. Choice D is incorrect as the client's denial is influenced by emotional factors.
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Which of the following is one reason given that more women than men are treated for psychological problems?
- A. Women are subject to greater stress than men
- B. As a result of cultural norms, women may be more willing to admit distress
- C. Some forms of mental disorders are sex-linked recessive
- D. Developmental tasks required of women are far more difficult than those required of men
Correct Answer: B
Rationale: Cultural norms often make women more likely to seek help, contributing to higher treatment rates.
A patient with anorexia nervosa is resistant to weight gain. What is the rationale for establishing a contract with the patient to participate in measures to produce a specified weekly weight gain?
- A. Severe anxiety concerning eating is expected, so objective and subjective data are needed.
- B. Patient involvement in decision-making increases sense of control and promotes collaboration.
- C. The patient's family is not supportive of the treatment plan.
- D. None of the above.
Correct Answer: B
Rationale: Correct Answer: B - Patient involvement in decision-making increases sense of control and promotes collaboration.
Rationale:
1. Involving the patient in decision-making empowers them and increases their sense of control over their treatment.
2. Collaborating with the patient fosters a positive therapeutic relationship.
3. This approach is more likely to lead to better treatment adherence and outcomes.
Summary:
A: While objective and subjective data are important, this choice does not address the need for patient involvement in decision-making and collaboration.
C: The lack of family support is not directly related to the rationale for establishing a contract with the patient.
D: This choice is incorrect as patient involvement is crucial in promoting successful treatment outcomes.
A patient has disorganized thinking associated with schizophrenia. Neuroimaging would most likely show dysfunction in which part of the brain?
- A. Hippocampus
- B. Frontal lobe
- C. Cerebellum
- D. Brainstem
Correct Answer: B
Rationale: The correct answer is B: Frontal lobe. Disorganized thinking in schizophrenia is often associated with executive function deficits, which are primarily controlled by the frontal lobe. This area is responsible for decision-making, problem-solving, and reasoning. Dysfunction here can lead to disorganized thoughts and behaviors. The other choices, such as the hippocampus (A), involved in memory, the cerebellum (C), involved in motor coordination, and the brainstem (D), involved in basic life functions, are less likely to be directly related to disorganized thinking in schizophrenia.
A patient received maintenance doses of fluphenazine decanoate (Prolixin Decanoate) 25 mg IM every 2 weeks for 2 years. The clinic nurse notes the patient is grimacing and seems to be constantly smacking her lips. On the next clinic visit, the patient's neck and shoulders twist in a slow, snakelike motion. The nurse should suspect the presence of ______ and should ______.
- A. agranulocytosis"¦check the patient's complete blood count for changes
- B. tardive dyskinesia"¦administer the Abnormal Involuntary Movement Scale
- C. Tourette's syndrome"¦consult the patient's physician about a neuro evaluation
- D. anticholinergic effects"¦consult the physician about possible medication changes
Correct Answer: B
Rationale: The correct answer is B: tardive dyskinesia"¦administer the Abnormal Involuntary Movement Scale.
1. Tardive dyskinesia is a side effect of long-term use of antipsychotic medications like fluphenazine.
2. The symptoms described - grimacing, lip smacking, twisting neck and shoulders - are characteristic of tardive dyskinesia.
3. Administering the Abnormal Involuntary Movement Scale is the appropriate assessment tool for diagnosing tardive dyskinesia.
4. Agranulocytosis (choice A) is a rare but serious side effect of some antipsychotic medications, not associated with the symptoms described.
5. Tourette's syndrome (choice C) typically presents with vocal and motor tics, not the specific symptoms mentioned.
6. Anticholinergic effects (choice D) can cause dry mouth, constipation, and blurred vision, but not the involuntary movements described.
A patient with schizophrenia who admits to auditory hallucinations anxiously tells the nurse, 'The voice is telling me to do things.' Which of the following responses should the nurse make next?
- A. Do you recognize the voice you hear?'
- B. How long has this been happening?'
- C. Does what the voice tells you to do frighten you?'
- D. What is the voice telling you to do?'
Correct Answer: D
Rationale: The correct answer is D: "What is the voice telling you to do?" This response helps the nurse assess the content and potential danger of the hallucinations, guiding further interventions. Option A focuses on recognition, which is less urgent. Option B addresses duration, not immediate safety. Option C inquires about fear but does not directly address the hallucination's content. By asking what the voice commands, the nurse gains crucial insight for risk assessment and safety planning.