Age Specific Care Competency

Age Specific Care Competency Related

Review Age Specific Care Competency related questions and content

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 victim of spousal abuse comes to the emergency department for treatment of a broken arm. She appears hypervigilant and anxious and admits to sleep disturbance when the nurse questions the dark circles under her eyes. She reluctantly tells the nurse the abuse usually occurs when the husband has been drinking, although she concedes he is always jealous and controlling. She is a stay-at-home mother of two preschool children. The family has lived in this town for 1 month. The patient states she has fleetingly considered suicide but must stay alive to care for her children and work her way out of the abusive relationship. She denies any further suicidal thoughts. The nurse should document in the medical record that: (Select all that apply.)

  • A. Signs of high anxiety and chronic stress are present.
  • B. The patient relies on the perpetrator for basic needs.
  • C. The patient has a history of suicidal ideation.
  • D. None of the above.
Correct Answer: A

Rationale: The correct answer is A: Signs of high anxiety and chronic stress are present.
Rationale:
1. The patient displaying hypervigilance, anxiety, sleep disturbances, and dark circles under her eyes are indicators of high anxiety and chronic stress, common in victims of abuse.
2. Mentioning abuse occurring when the husband drinks, his jealousy, and control further support the presence of chronic stress and anxiety.
3. The patient's fleeting suicidal thoughts are a response to the abusive situation, not indicative of a history of suicidal ideation.

Summary:
B: The patient relying on the perpetrator for basic needs is not supported by the information provided.
C: There is no indication of a history of suicidal ideation, as the patient's thoughts are tied to her children and escaping the abusive relationship.

Which intervention would be the best initial approach for a nurse to take when a young adult patient is verbally abusive?

  • A. Ask the patient to define 'verbally abusive language.'
  • B. Provide the patient with examples of assertive communication.
  • C. Identify the patient's verbal abuse in order to set standards for future dialogue.
  • D. Remove privileges from the patient until communications show less aggression.
Correct Answer: C

Rationale: The correct initial approach is to identify the patient's verbal abuse to set standards for future dialogue. This approach addresses the behavior directly, establishes boundaries, and communicates expectations for respectful communication. Asking the patient to define 'verbally abusive language' (choice A) may not effectively address the current behavior. Providing examples of assertive communication (choice B) may not directly address the abusive behavior. Removing privileges (choice D) may escalate the situation and is not a constructive communication strategy. By identifying the patient's verbal abuse, the nurse can address the behavior effectively and work towards a respectful and therapeutic relationship.

The chief distinguishing feature of psychotic disorders is

  • A. confusion of fantasy and reality
  • B. antisocial conduct
  • C. overwhelming anxiety
  • D. obsessive behavior
Correct Answer: A

Rationale: Psychotic disorders are characterized by a loss of reality testing, such as hallucinations and delusions, distinguishing them from other conditions.

Which of the following is not a common type of water pollutant?

  • A. Protists
  • B. Bacteria
  • C. Particulates
  • D. Carbon Monoxide
Correct Answer: D

Rationale: Carbon Monoxide is an air pollutant, not a common water pollutant, unlike protists, bacteria, and particulates.

A patient has schizophrenia and is troubled by negative symptoms, muscle stiffness, and motor restlessness. His Advanced Practice Nurse (APN) is considering changing the patient's antipsychotic medication, haloperidol (Haldol, a typical or first generation antipsychotic drug). For planning purposes, which medication can the nurse assume that the APN will probably choose?

  • A. Chlorpromazine (Thorazine)
  • B. Clozapine (Clozaril)
  • C. Olanzapine (Zyprexa)
  • D. Fluoxetine (Prozac)
Correct Answer: C

Rationale: The correct answer is C: Olanzapine (Zyprexa). Olanzapine is an atypical or second-generation antipsychotic that is effective in treating both positive and negative symptoms of schizophrenia. It also has a lower risk of causing extrapyramidal symptoms like muscle stiffness and motor restlessness compared to typical antipsychotics like haloperidol. Chlorpromazine (A) is a typical antipsychotic with similar side effects as haloperidol. Clozapine (B) is an atypical antipsychotic that is effective for treatment-resistant schizophrenia but is usually considered as a last resort due to its potential for serious side effects. Fluoxetine (D) is an antidepressant and not typically used as a first-line treatment for schizophrenia.

Copyright © 2025 Nokea. All rights reserved.