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A client tried to gouge out his eye in response to auditory hallucinations commanding, 'If thine eye offend thee, pluck it out.' The nurse would analyze this behavior as indicating:
- A. Impaired impulse control
- B. Inability to manage anger
- C. Derealization
- D. Inappropriate affect
Correct Answer: A
Rationale: The correct answer is A: Impaired impulse control. This behavior shows a lack of control over impulsive actions, as the client acted immediately on the auditory hallucination without considering the consequences. Choice B is incorrect because anger management is not directly related here. Choice C, derealization, refers to feeling disconnected from reality, which is not evident in the scenario. Choice D, inappropriate affect, does not fit as the client's action is more about impulsivity than emotional expression. Ultimately, the client's behavior aligns most closely with impaired impulse control due to the immediate and extreme response to the auditory hallucination.
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A nurse is providing education to a patient with anorexia nervosa. Which of the following statements indicates a need for further education?
- A. I understand that my body needs food to function properly.
- B. I am willing to work on gaining weight with the help of my care team.
- C. I believe that eating food will make me fat and out of control.
- D. I am ready to learn how to improve my relationship with food.
Correct Answer: C
Rationale: The correct answer is C because the statement reflects a common misconception associated with anorexia nervosa, indicating a need for further education. Here's the rationale:
1. Anorexia nervosa involves a distorted body image and fear of gaining weight.
2. Believing that eating food will make one fat and out of control aligns with these distorted beliefs.
3. This statement demonstrates a lack of understanding and acceptance of the importance of proper nutrition for health.
4. Choices A, B, and D show positive attitudes towards recovery and willingness to address the disorder, highlighting a better understanding of the condition.
In summary, choice C shows a need for further education due to the presence of distorted beliefs, while the other options reflect a more positive and informed mindset towards recovery.
The male manager of a health club placed a hidden video camera in the women's locker room and recorded several women as they showered and dressed. The disorder most likely represented by this behavior is
- A. homosexuality.
- B. exhibitionism.
- C. pedophilia.
- D. voyeurism.
Correct Answer: D
Rationale: The correct answer is D: voyeurism. Voyeurism is a disorder characterized by the act of observing an unsuspecting individual who is naked, in the process of undressing, or engaging in sexual activity, for the purpose of sexual gratification. In this scenario, the male manager is surreptitiously recording women in the locker room without their consent, indicating voyeuristic behavior.
A: Homosexuality is the sexual orientation of being attracted to individuals of the same gender and is not relevant to the scenario.
B: Exhibitionism involves exposing one's genitals to others for sexual gratification, which is not the case in this scenario.
C: Pedophilia is a disorder characterized by an adult's sexual interest in prepubescent children, which is not applicable in this scenario.
In summary, the behavior of the male manager aligns with voyeurism due to the secret recording of women in the locker room for sexual gratification.
A nurse caring for a patient with Alzheimer disease can anticipate that the family will most likely need information about:
- A. antimetabolites.
- B. benzodiazepines.
- C. immunosuppressants.
- D. acetylcholinesterase inhibitors.
Correct Answer: D
Rationale: The correct answer is D: acetylcholinesterase inhibitors. Patients with Alzheimer's disease often benefit from this type of medication to help improve cognitive function. The family would need information on this to understand the treatment plan. Antimetabolites (A), benzodiazepines (B), and immunosuppressants (C) are not typically used in the treatment of Alzheimer's disease and would not be relevant for the family to know about in this context.
The home care nurse assessed a client with a history of dementia who had a herniorrhaphy at an ambulatory surgical center the previous day. The client lives in a senior living facility. The client thinks he is in the army and that it is 1945. The nurse should:
- A. Reorient the client to the current time and place.
- B. Notify the client's family of the confusion.
- C. Document the client's confusion and disorientation.
- D. None of the above.
Correct Answer: A
Rationale: The correct answer is A: Reorient the client to the current time and place. The nurse should reorient the client to prevent distress and promote safety. This approach helps the client feel more secure and may reduce confusion. Choice B is incorrect because the nurse should address the client's needs first. Choice C is not enough on its own as the nurse needs to actively assist the client. Choice D is incorrect as action is needed in this situation to support the client.
Early manifestation of symptoms such as severe impairment in social interaction and in communication can be diagnosed as which of the following?
- A. Infantile autism
- B. Infantile amnesia
- C. Cerebral palsy
- D. Rett's syndrome
Correct Answer: A
Rationale: Infantile Autism: Early manifestations of Autistic Disorder symptoms, including impaired social interaction and communication.