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A client with schizophrenia tells the nurse as they sit in the day room, 'I hear voices telling me bad things.' The most therapeutic response the nurse can make is:
- A. Tell me what the voices are saying.'
- B. I understand you hear these so-called voices, but I hear only the people in the room talking.'
- C. The voices are not real. They're only your imagination.'
- D. Do you think the voices would go away if we went into your room to talk?'
Correct Answer: B
Rationale: The correct answer is B because it demonstrates empathy and validation of the client's experience. By acknowledging the client's reality of hearing voices and emphasizing that the nurse does not hear them, the nurse establishes trust and rapport. This response shows active listening and validates the client's feelings without judgment.
Incorrect responses:
A: Asking the client to describe the voices may increase distress and is not as supportive as acknowledging their experience.
C: Dismissing the voices as not real can invalidate the client's experience and may lead to mistrust.
D: Suggesting a change of location does not address the client's immediate concerns and may not be therapeutic in this situation.
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A nurse plans an educational program for staff of a home health agency specializing in care of the elderly. Which topic is the highest priority to include?
- A. Pain assessment techniques for older adults
- B. Psychosocial stimulation for those who live alone
- C. Preparation of psychiatric advance directives in the elderly
- D. Ways to manage disinhibition in elderly persons with dementia
Correct Answer: A
Rationale: The topic of greatest immediacy is the assessment of pain in older adults. Unmanaged pain can precipitate other problems, such as substance abuse and depression. Elderly patients are less likely to be accurately diagnosed and adequately treated for pain. The distracters are unrelated or of lesser importance.
A boy with a conduct disorder diagnosis would be most likely to have which symptom?
- A. Withdrawal
- B. Ritualistic behavior
- C. Class bully
- D. Class clown
Correct Answer: C
Rationale: A pattern of bullying is a common sign of conduct disorder. Responses A and B may reflect autism.
Which of the following is a characteristic behavior in patients with anorexia nervosa?
- A. Binge eating followed by purging.
- B. Extreme weight loss due to excessive food restriction.
- C. Frequent overeating with a lack of control.
- D. Excessive weight gain through overeating and exercise.
Correct Answer: B
Rationale: The correct answer is B: Extreme weight loss due to excessive food restriction. Patients with anorexia nervosa typically exhibit severe food restriction leading to significant weight loss. This behavior is driven by a distorted body image and fear of gaining weight. Binge eating followed by purging (choice A) is characteristic of bulimia nervosa, not anorexia nervosa. Frequent overeating with a lack of control (choice C) is a feature of binge eating disorder, not anorexia nervosa. Excessive weight gain through overeating and exercise (choice D) does not align with the weight loss seen in anorexia nervosa.
A young patient diagnosed with schizophrenia is standing naked after showering and appears to be both dazed and indecisive. The nursing intervention that will be most helpful to promote dressing would be:
- A. saying, 'These are your clothes. Please get dressed.'
- B. saying, 'These are your underpants. I'll help you put them on.'
- C. asking, 'Which of these two outfits would you like to wear now?'
- D. asking, 'Is something the matter with your clothes that makes you not want to dress?'
Correct Answer: B
Rationale: The correct answer is B. By saying, "These are your underpants. I'll help you put them on," the nurse provides clear guidance and offers assistance, which can help the patient feel more comfortable and supported in the dressing process. This approach acknowledges the patient's need for help while respecting their autonomy.
Choice A is too directive and may make the patient feel pressured or overwhelmed. Choice C involves too many options, which can be confusing for a patient experiencing indecisiveness. Choice D assumes a problem with the clothes rather than focusing on the patient's needs and feelings. Overall, choice B is the most appropriate and supportive intervention in this situation.
Which nursing diagnosis is most appropriate for a patient with bulimia nervosa who engages in frequent purging behaviors?
- A. Ineffective coping related to inability to control impulses.
- B. Risk for injury related to electrolyte imbalances.
- C. Imbalanced nutrition: less than body requirements related to food refusal.
- D. Disturbed body image related to fear of weight gain.
Correct Answer: B
Rationale: The correct answer is B: Risk for injury related to electrolyte imbalances. Patients with bulimia nervosa who engage in frequent purging behaviors are at risk for electrolyte imbalances due to loss of potassium, sodium, and other essential minerals. This can lead to serious complications such as cardiac arrhythmias and organ damage. Monitoring and addressing electrolyte imbalances is crucial in the care of these patients to prevent potential harm.
A: Ineffective coping related to inability to control impulses is not the most appropriate diagnosis as it does not directly address the immediate risk of electrolyte imbalances in this scenario.
C: Imbalanced nutrition: less than body requirements related to food refusal is not the most appropriate diagnosis as the primary concern in bulimia nervosa with purging behaviors is the risk of electrolyte imbalances, not necessarily inadequate food intake.
D: Disturbed body image related to fear of weight gain is not the most appropriate diagnosis as it does not address the immediate physical health risks