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A client experiences intrusive, insulting auditory hallucinations. Which independent behavioral technique can the nurse teach the client to employ when the voices are troublesome?
- A. Take additional antipsychotic medication
- B. Lie down in bed and try to sleep
- C. Sing or whistle to compete with the voices
- D. Eat a large portion of chocolate
Correct Answer: C
Rationale: The correct answer is C: Sing or whistle to compete with the voices. This technique is effective as it can help distract the client from the intrusive auditory hallucinations. By engaging in singing or whistling, the client can shift their focus away from the voices, making them less bothersome. This method can also empower the client by giving them a sense of control over the situation.
Other choices are incorrect:
A: Taking additional antipsychotic medication may not be necessary in this situation and should be prescribed by a healthcare provider.
B: Lying down and trying to sleep may not address the immediate distress caused by the hallucinations.
D: Eating a large portion of chocolate is not a valid behavioral technique for managing auditory hallucinations.
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An Arab student new to an elementary school reports, 'I just don't want to go to gym class.' Which factor would be of primary concern for a school nurse?
- A. The student's family's cultural beliefs regarding females interacting with males in public
- B. Complaints from others of 'bullying' that occurs in gym class
- C. The student's problems adjusting to the new school environment
- D. A teacher's concern that the gym class is overcrowded
Correct Answer: B
Rationale: The correct answer is B because the primary concern for the school nurse would be addressing any potential bullying the Arab student is experiencing in gym class. This is important for the student's well-being and mental health. Choice A is not the primary concern as it does not directly address the student's reluctance to attend gym class. Choice C focuses on general adjustment issues, while choice D pertains to a logistical issue rather than the student's emotional or social well-being. Addressing bullying is crucial to creating a safe and inclusive environment for the student.
The most widely used system of psychological classification today is
- A. the Freudian Psychoanalytic System (FPS)
- B. found in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)
- C. the system designed by Emil Kraepelin and Eugen Bleuler
- D. to be found in the Federal Uniform Code of Psychopathology (UCP)
Correct Answer: B
Rationale: The DSM-IV (now DSM-5) is the standard diagnostic system globally used in psychology.
A client who has been diagnosed as having paranoid schizophrenia is highly suspicious and delusional. He hears voices telling him terrorists are plotting to assassinate him. He refuses to eat, saying the food is poisoned. The nursing action that best addresses his needs is to:
- A. Explain that others eat the food and are not harmed
- B. Allow client to select food from vending machines
- C. Assist client with personal hygiene and grooming
- D. Not allow client to verbalize delusional thoughts
Correct Answer: B
Rationale: The correct answer is B: Allow client to select food from vending machines. This option respects the client's autonomy and addresses his delusion about the food being poisoned. By allowing the client to choose food from vending machines, it acknowledges his concerns and promotes a sense of control over his environment. This approach can help build trust and rapport with the client, as forcing him to eat regular hospital food might exacerbate his paranoia and resistance.
A: Explaining that others eat the food and are not harmed may not be effective as it disregards the client's beliefs and could further alienate him.
C: Assisting with personal hygiene and grooming is important but does not directly address the client's primary concern of refusing to eat due to delusional beliefs.
D: Not allowing the client to verbalize delusional thoughts is counterproductive as it suppresses communication and does not address the underlying issue of the client's fear of being poisoned.
Which theme is most likely during family therapy with parents, siblings, and a teen patient with anorexia nervosa who engages in provocative behavior?
- A. Stable coalitions between family members
- B. Interpreting negative messages as positive
- C. Competition between the patient and father
- D. Lack of trust in the patient by family members
Correct Answer: C
Rationale: The correct answer is C: Competition between the patient and father. In family therapy with a teen patient with anorexia nervosa, the theme of competition between the patient and a parental figure, often the father, can be prominent. The rationale is that the father's influence and expectations can contribute to the teen's feelings of inadequacy and drive for control through anorexic behaviors. This dynamic can be explored and addressed in therapy to improve family relationships and support the patient's recovery.
A: Stable coalitions between family members - This is less likely as anorexia nervosa often disrupts family dynamics.
B: Interpreting negative messages as positive - While this can be a relevant theme, it is not as central to the specific scenario described.
D: Lack of trust in the patient by family members - While trust issues may exist, the theme of competition is more relevant in this context.
Which complication should a nurse monitor for when treating a patient with bulimia nervosa who is experiencing frequent vomiting?
- A. Hypokalemia and dental enamel erosion.
- B. Hyperkalemia and elevated blood pressure.
- C. Severe dehydration and low blood sugar.
- D. Hypercalcemia and weight gain.
Correct Answer: A
Rationale: The correct answer is A: Hypokalemia and dental enamel erosion.
1. Bulimia nervosa involves frequent vomiting, leading to loss of potassium (hypokalemia) due to electrolyte imbalance.
2. Vomiting also damages tooth enamel, causing dental erosion.
3. Hyperkalemia and elevated blood pressure (choice B) are not typically associated with bulimia.
4. Severe dehydration and low blood sugar (choice C) are possible but not the primary concerns.
5. Hypercalcemia and weight gain (choice D) are not common complications of bulimia.