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A delusion is defined as seeing something that is not real
- A. TRUE
- B. FALSE
Correct Answer: B
Rationale: A delusion is a fixed false belief, not a perception (hallucination involves seeing/hearing something not real).
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Which of the following is a critical aspect of nursing care for patients with anorexia nervosa?
- A. Encouraging weight loss to avoid complications from obesity.
- B. Promoting normalization of eating habits and nutritional rehabilitation.
- C. Restricting fluid intake to reduce risk of water retention.
- D. Avoiding any pressure for the patient to gain weight rapidly.
Correct Answer: B
Rationale: The correct answer is B: Promoting normalization of eating habits and nutritional rehabilitation. This is critical in anorexia nervosa treatment to address malnutrition and restore a healthy relationship with food. Encouraging weight loss (A) is inappropriate as these patients are already underweight. Restricting fluid intake (C) can worsen dehydration and electrolyte imbalances. Avoiding pressure for rapid weight gain (D) is important, but the primary focus should be on promoting healthy eating habits and gradual weight restoration. By focusing on normalization of eating habits and nutritional rehabilitation, nurses can help patients with anorexia nervosa recover physically and mentally.
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.
A community mental health nurse receives a new client for his caseload. The diagnosis of the client is residual schizophrenia. Documentation states that the client has a number of negative symptoms. Which symptom would the nurse expect to assess in the client?
- A. Bizarre, somatic delusions
- B. Disorganized speech pattern
- C. Catatonic posturing
- D. Emotional blunting
Correct Answer: D
Rationale: The correct answer is D: Emotional blunting. In residual schizophrenia, negative symptoms are prominent, including emotional blunting which refers to a reduced ability to express emotions. This is commonly seen in clients with residual schizophrenia.
Explanation of why other choices are incorrect:
A: Bizarre, somatic delusions are characteristic of paranoid schizophrenia, not residual schizophrenia.
B: Disorganized speech pattern is a symptom of disorganized schizophrenia, not residual schizophrenia.
C: Catatonic posturing is associated with catatonic schizophrenia, not residual schizophrenia.
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.
A frequent finding in clients with Paraphiliac sexual disorders is that they have:
- A. Other covert or overt emotional
- B. Gonadal and pituitary hormone deficiencies
- C. An inadequate physical development of the sex organs
- D. A poor adjustment due to association with society's fringe groups
Correct Answer: A
Rationale: Clients with paraphilic disorders often have coexisting emotional disorders, which may contribute to or result from their condition.