Nokea
A client with schizophrenia tells the nurse that he is the President of the United States, and no logical reasoning with the client convinces him otherwise. This client is experiencing a:
- A. Mutism
- B. Delusion
- C. Neologism
- D. Flight of ideas
Correct Answer: B
Rationale: The correct answer is B: Delusion. A delusion is a fixed false belief that is not based on reality, such as believing one is a famous figure like the President. In this scenario, the client's belief is firmly held despite evidence to the contrary, indicating a delusion. Mutism (A) is a lack of verbal communication, not applicable here. Neologism (C) is creating new words or phrases, not seen in this example. Flight of ideas (D) is a rapid, continuous flow of speech with abrupt topic changes, which is not demonstrated in the client's behavior described.
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The psychiatric-mental health nurse, who is teaching a patient's parents how to use positive reinforcement techniques with the patient, recommends:
- A. agreeing with the child's statements, whether negative or positive, and simply restating the child's statements without other comment
- B. controlling the child's behavior, so there is no chance of negative behavior
- C. removing adverse consequences to produce positive results
- D. rewarding positive behaviors to promote their recurrence
Correct Answer: D
Rationale: Positive reinforcement rewards desired behaviors, increasing their frequency, a core behavioral strategy.
The outcome that should be established for an elderly patient with delirium caused by fever and dehydration is that the patient will:
- A. Return to a premorbid level of functioning.
- B. Demonstrate motor responses to noxious stimuli.
- C. Identify stressors negatively affecting self.
- D. None of the above.
Correct Answer: A
Rationale: The correct answer is A because the goal in managing delirium in an elderly patient is to restore them to their premorbid level of functioning. This involves addressing the underlying causes like fever and dehydration. Option B is incorrect as it focuses on a neurological response rather than the overall outcome for the patient. Option C is also incorrect as it pertains to identifying stressors, which is not the primary goal in managing delirium. Option D is incorrect as it dismisses the importance of restoring the patient to their baseline level of functioning.
A 75-year-old patient comes to the clinic reporting frequent headaches. As the nurse begins the interaction, which action is most important?
- A. Complete a neurological assessment
- B. Determine whether the patient can hear as the nurse speaks
- C. Suggest that the patient lie down in a darkened room for a few minutes
- D. Administer medication to relieve the patient's pain before continuing the assessment
Correct Answer: B
Rationale: Correct Answer: B. Determine whether the patient can hear as the nurse speaks.
Rationale:
1. Hearing assessment is crucial to ensure patient understanding and communication.
2. Hearing loss may affect compliance with treatment and safety.
3. Identifying hearing deficits early can prevent misunderstandings and improve patient outcomes.
Summary:
- A: While a neurological assessment may be necessary, addressing hearing first is more immediate.
- C: Suggesting rest may help with headache management, but addressing hearing is more critical.
- D: Administering medication is premature without assessing hearing first.
Which nursing strategy leads patients to respond more positivity to limit setting?
- A. Confront the patient with the inappropriateness of the behavior.
- B. Explore with the patient the underlying dynamics of the behavior.
- C. Reflect back to the patient an understanding of the patient's distress.
- D. State clear disapproval of the behavior, and support its consequences.
Correct Answer: C
Rationale: The correct answer is C because reflecting back to the patient an understanding of their distress shows empathy and validation, which can help build rapport and trust. By acknowledging the patient's feelings, it can help them feel heard and understood, leading to a more positive response to limit setting.
Choice A is incorrect because confrontation can lead to defensiveness and resistance. Choice B focuses on exploring underlying dynamics without addressing the immediate behavior. Choice D may come off as judgmental and punitive, potentially escalating the situation.
A client with borderline personality disorder is having difficulty with memories of sexual abuse. She has a history of suicidal gestures, self-mutilation, sexual addiction, and substance addiction. She complains of vague pains, menstrual problems, and headaches. She entered the partial hospital program to prevent another suicide gesture or self-mutilation. The nurse recognizes that collaborative therapy may be helpful for this client and knows that the most useful collaboration in this case would be the client, the nurse, and the:
- A. Occupational therapist exploring ways to reduce stress
- B. Physical therapist exploring ways to reduce back pain
- C. Acupuncturist exploring ways to reduce pain
- D. Sexologist exploring healthy sexuality and safe sex
Correct Answer: A
Rationale: The correct answer is A: Occupational therapist exploring ways to reduce stress. In this case, the client's symptoms and history suggest complex emotional issues related to trauma and addiction. Occupational therapy can help the client develop coping skills, manage stress, and improve functioning in daily activities. The therapist can work collaboratively with the client and nurse to address the client's emotional, physical, and social needs.
Choice B: Physical therapist exploring ways to reduce back pain focuses only on physical symptoms and does not address the underlying emotional issues. Choice C: Acupuncturist exploring ways to reduce pain also only addresses physical symptoms and does not provide comprehensive support for the client's mental health. Choice D: Sexologist exploring healthy sexuality and safe sex is not the most immediate need for the client, as her primary concerns are related to trauma, self-harm, and addiction.