Nokea
A client with catatonic schizophrenia has been posturing, standing with his left arm upraised and his right foot off the floor. For the most part, he ignores attempts at nursing intervention but will occasionally walk, sit, or lie down for a few minutes. The client eats standing up if the nurse brings a tray to the room. The priority nursing order would be to:
- A. Insist that client sit or lie down for 30 minutes hourly
- B. Assess for lower extremity edema bid
- C. Provide high-calorie drinks hourly
- D. Take client to activities therapy once daily
Correct Answer: B
Rationale: The correct answer is B. Assess for lower extremity edema bid.
Rationale:
1. Priority is to assess for lower extremity edema as the client is standing for extended periods, which can lead to edema.
2. Edema assessment is crucial for preventing complications like blood clots or skin breakdown.
3. Insisting on sitting or lying down may aggravate the client and worsen the situation.
4. Providing high-calorie drinks or activities therapy are not the immediate priority in this case.
In summary, assessing for lower extremity edema is crucial due to the client's prolonged standing, which can lead to potential health risks, making it the priority nursing order.
You may also like to solve these questions
A novice nurse tells the assigned mentor, 'I admitted a patient today who has several bizarre delusions. I wanted to tell the patient that the ideas and conclusions simply are not logical. What do you think will happen if I do?' Which reply by the mentor is best?
- A. I think you'll give the patient something to think about.'
- B. The patient will probably incorporate you into the delusions as a persecutor.'
- C. Develop trust using empathy and calmness before pointing out discrepancies.'
- D. Initially, it would be better to go along with the patient's thinking to gain cooperation.'
Correct Answer: C
Rationale: The correct answer is C because it emphasizes the importance of developing trust and rapport with the patient before addressing their delusions. By using empathy and calmness, the nurse can create a safe environment for the patient to feel understood and supported. This approach can help the patient be more receptive to feedback about the discrepancies in their thinking.
Choice A is incorrect because simply giving the patient something to think about may not address the underlying issues causing the delusions.
Choice B is incorrect as it assumes the patient will view the nurse negatively, which may not always be the case.
Choice D is incorrect as it suggests going along with the patient's delusions, which can potentially reinforce and perpetuate their false beliefs.
A patient who has been taking fluoxetine (Prozac) 60 mg daily for the past 6 months tells the nurse at the medication follow-up clinic that he is considering stopping the Prozac. He states his mood is fine, and now that he is living normally, his wife is concerned that he has no sex drive. Which response would be best?
- A. Without the medicine the depression will likely return; you and your wife will need to adjust to the sexual side effects.
- B. If we switch your medication time to the morning, the sexual side effects will be worn off in time for evening sexual activity.
- C. The problem is not likely due to the medicine. Often the depression itself, even after it improves, continues to dampen sex drive.
- D. Without an antidepressant, the depression is more likely to reoccur, but there are other medications that do not interfere so much with sex.
Correct Answer: D
Rationale: Step-by-step rationale for why answer D is correct:
1. Correctly acknowledges the patient's concern about sexual side effects.
2. Highlights the importance of managing depression to prevent recurrence.
3. Offers a solution by mentioning alternative medications with less impact on sex drive.
4. Empowers the patient by providing information and options for treatment.
5. Addresses both the patient's current situation and long-term mental health needs.
Summary of why other choices are incorrect:
A: Overlooks the patient's valid concern about sexual side effects and lacks a proactive solution.
B: Focuses on timing of medication without addressing the underlying issue of sexual side effects.
C: Dismisses the patient's concern and fails to provide a solution or alternative options.
Select the central concept around which a family education plan for preventing childhood eating problems is constructed:
- A. Promoting self-demand feeding for the child.
- B. Distinguishing between physical and psychological hunger.
- C. Scheduling meals because children do not recognize physical hunger.
- D. Parental expectations of ideal intake as determinants of healthy eating habits.
Correct Answer: A
Rationale: The correct answer is A: Promoting self-demand feeding for the child. This approach encourages the child to listen to their own hunger cues and regulate their food intake accordingly, promoting a healthy relationship with food. It empowers the child to develop autonomy and self-awareness around eating habits.
Explanation for why the other choices are incorrect:
B: While distinguishing between physical and psychological hunger is important, it is not the central concept for preventing childhood eating problems.
C: Scheduling meals may not align with the child's natural hunger cues and can potentially lead to disordered eating patterns.
D: Parental expectations can create pressure around eating, potentially leading to negative relationships with food.
Trends that have contributed to the recent increase in eating disorders in the United States include a(n):
- A. more competitive workplace.
- B. increase in the number of divorces.
- C. focus on being thin as a measure of attractiveness.
- D. increase in the number of nonnutritional foods consumed.
Correct Answer: C
Rationale: The correct answer is C: focus on being thin as a measure of attractiveness. This is because societal pressures and media influence have placed a strong emphasis on thinness as the ideal body type, leading to increased body dissatisfaction and disordered eating behaviors. Option A (more competitive workplace) and B (increase in the number of divorces) are not directly linked to eating disorders, while option D (increase in the number of nonnutritional foods consumed) may contribute to health issues but not specifically to eating disorders. In conclusion, the societal focus on thinness has a significant impact on the rise of eating disorders in the United States.
A patient with borderline personality disorder cut her wrists while out on a pass. For future planning, staff should consider that the reason for the self-mutilation is probably related to:
- A. an inherited disorder that manifests itself as an incapacity to tolerate stress.
- B. fear of abandonment associated with relationships or increasing autonomy.
- C. use of projective identification and splitting to bring anxiety to manageable levels.
- D. a constitutional inability to regulate affect, predisposing to psychic disorganization.
Correct Answer: B
Rationale: Correct Answer: B
Rationale:
1. Borderline personality disorder is characterized by fear of abandonment.
2. Self-mutilation can be a maladaptive coping mechanism to alleviate this fear.
3. The behavior is often triggered by perceived threats to relationships or autonomy.
4. Therefore, considering fear of abandonment in future planning is crucial.
Summary of other choices:
A: Inherited disorder is not the primary reason for self-mutilation in borderline personality disorder.
C: Projective identification and splitting are defense mechanisms, not primary reasons for self-mutilation.
D: Constitutional inability to regulate affect may contribute, but fear of abandonment is more central in borderline personality disorder.