Nokea
A client tells the RN that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. What is the priority nursing problem for admission to the psychiatric unit?
- A. Ineffective sexual patterns.
- B. Impaired environmental interpretation.
- C. Disturbed sensory perception.
- D. Compromised family coping.
Correct Answer: C
Rationale: The correct answer is C: Disturbed sensory perception. The client's delusions and false beliefs indicate a break from reality, which is a hallmark symptom of disturbed sensory perception. This poses a risk to the client's safety and well-being. Ineffective sexual patterns (choice A) and compromised family coping (choice D) may be secondary to the primary issue of distorted perceptions. Impaired environmental interpretation (choice B) is less relevant as the client's issues are more internal. Overall, addressing the disturbed sensory perception is the priority to ensure the client's safety and initiate appropriate treatment.
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To provide effective care for the patient diagnosed with schizophrenia, the nurse should frequently assess for which associated condition? Select all that apply.
- A. Alcohol use disorder
- B. Major depressive disorder
- C. Stomach cancer
- D. Polydipsia
Correct Answer: A
Rationale: The correct answer is A: Alcohol use disorder. Patients with schizophrenia are at higher risk for co-occurring substance use disorders, including alcohol use disorder. Assessing for alcohol use is crucial as it can worsen symptoms and interfere with treatment. Major depressive disorder (B) is a common comorbidity but is not specific to schizophrenia. Stomach cancer (C) is not directly associated with schizophrenia. Polydipsia (D), excessive thirst, can be seen in schizophrenia due to medication side effects but is not a primary associated condition.
In pediatric mental health there is a lack of sufficient numbers of community-based resources and providers, and there are long waiting lists for services. This has resulted in: Select all that apply.
- A. Children of color and poor economic conditions being underserved
- B. Increased stress in the family unit
- C. Markedly increased funding
- D. Premature termination of services
Correct Answer: D
Rationale: Correct Answer: D. Premature termination of services
Rationale: The lack of community-based resources and providers, along with long waiting lists, can lead to premature termination of services in pediatric mental health. When families face difficulties accessing timely and continuous care, they may discontinue treatment prematurely, impacting the effectiveness of interventions. This can result in negative outcomes for children, such as unaddressed mental health issues and increased risk of relapse.
Summary:
A: Children of color and poor economic conditions being underserved - While this may be a consequence of the lack of resources, it is not directly caused by premature termination of services.
B: Increased stress in the family unit - While this may be a consequence of the situation, it is not directly caused by premature termination of services.
C: Markedly increased funding - While increased funding could help address the lack of resources, it is not directly related to premature termination of services.
When developing a plan of care for a client admitted to the psychiatric unit following aspiration of a caustic material related to a suicide attempt, which nursing problem has the highest priority?
- A. Impaired comfort.
- B. Risk for injury.
- C. Ineffective breathing pattern.
- D. Ineffective coping.
Correct Answer: C
Rationale: The correct answer is C: Ineffective breathing pattern. This is the highest priority because aspiration of a caustic material can lead to respiratory distress or compromise. Ensuring the client has a patent airway and adequate breathing is crucial for immediate stabilization and preventing further complications. Impaired comfort (choice A) may be a concern but is secondary to ensuring the client can breathe. Risk for injury (choice B) is important but not as immediate as addressing breathing. Ineffective coping (choice D) is important for long-term recovery but addressing the client's breathing takes precedence in this acute situation.
An RN is providing education to the family of a client diagnosed with schizophrenia who is being treated with clozapine (Clozaril). The RN should instruct the family to report which symptom immediately?
- A. Sore throat
- B. Weight loss
- C. Constipation
- D. Lightheadedness
Correct Answer: A
Rationale: The correct answer is A: Sore throat. Clozapine can cause agranulocytosis, a potentially life-threatening condition characterized by a decrease in white blood cells. Sore throat could indicate an infection, necessitating immediate medical attention to monitor for agranulocytosis. Weight loss (B) and constipation (C) are common side effects of clozapine but do not require immediate reporting. Lightheadedness (D) may be a side effect but not as urgent as a sore throat in this case.
When preparing to administer to domestic violence screening tool to a female client, which statement should the RN provide?
- A. If your partner is abusing you, I need to ask these questions.
- B. State law mandates that I ask if you are a victim of domestic violence.
- C. The HCP provider needs to know if you are experiencing any domestic abuse.
- D. All clients are screened for domestic abuse because it is common in our society.
Correct Answer: D
Rationale: The correct answer is D. By stating that all clients are screened for domestic abuse because it is common in society, the nurse normalizes the screening process and reduces stigma. This approach can help the client feel more comfortable disclosing abuse. Choice A may inadvertently imply that the client's partner is abusing them, potentially leading to a defensive response. Choice B may make the client feel obligated to disclose abuse due to legal reasons, which can feel coercive. Choice C is vague and may not convey the importance of screening for domestic violence.