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A homeless patient diagnosed with a serious mental illness became suspicious and delusional. Depot antipsychotic medication began, and housing was obtained in a local shelter. One month later, which statement by the patient indicates significant improvement?
- A. They will not let me drink. They have many rules in the shelter.'
- B. I feel comfortable here. Nobody bothers me.'
- C. Those shots make my arm very sore.'
- D. Those people watch me a lot.'
Correct Answer: B
Rationale: Evaluation of a patients progress is made based on patient satisfaction with the new health status and the health care teams estimation of improvement. For a formerly delusional patient to admit to feeling comfortable and free of being bothered by others denotes improvement in the patients condition. The other options suggest that the patient is in danger of relapse.
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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.
A patient has not come out of her room for breakfast. The nurse finds the patient moving restlessly about her room in a disorganized manner. The patient is talking to herself, and her verbal responses to the nurse are nonsensical and suggest disorientation. The nurse notices that the patient's skin is hot and dry, and her pupils are somewhat dilated. All these symptoms are significant departures from the patient's recent presentation. The patient is likely experiencing ______, and the nurse should ______.
- A. anticholinergic toxicity"¦check vital signs and prepare to use a cooling blanket stat
- B. relapse of her psychosis"¦administer PRN antipsychotic drugs and notify her physician
- C. neuroleptic malignant syndrome"¦contact her physician for a transfer to intensive care
- D. agranulocytosis"¦hold her antipsychotic and draw blood for a complete blood count
Correct Answer: A
Rationale: The correct answer is A: anticholinergic toxicity. The patient's symptoms align with this diagnosis due to the disorganized behavior, nonsensical speech, disorientation, hot and dry skin, dilated pupils, and recent presentation changes. Anticholinergic toxicity can cause confusion, delirium, hyperthermia, and dilated pupils. Checking vital signs and preparing to use a cooling blanket are appropriate actions to manage the symptoms.
Choice B (relapse of psychosis) is incorrect because the symptoms are not typical of a psychotic relapse. Choice C (neuroleptic malignant syndrome) is incorrect as the symptoms do not completely align with this syndrome, which typically includes muscle rigidity and autonomic dysfunction. Choice D (agranulocytosis) is incorrect because it presents with low white blood cell count and not the symptoms described in the scenario.
The intervention that would be most appropriate of a male client develops orthostatic hypotension while taking amitriptyline (Elavil) is
- A. Consulting with the physician about substituting a different type of antidepressant
- B. Advising the client to sit up for 1 minute before getting out of bed
- C. Instructing the client to double the dosage until the problem resolves.
- D. Instruct the client to stop medication immediately
Correct Answer: B
Rationale: Advising the client to sit up slowly helps manage orthostatic hypotension, a common side effect of amitriptyline, by preventing sudden drops in blood pressure.
A patient has recently been under significant stress and worked long hours. At home, the patient watches television and eats until going to bed. The patient is too tired to exercise and has gained 25 pounds in 1 month. A desired outcome for the patient is to recognize anxiety that precedes binge eating and reduce it. Which intervention addresses the outcome?
- A. Teach stress-reduction techniques such as relaxation and imagery.
- B. Encourage the patient to design and implement an exercise program.
- C. Explore ways in which the patient may feel more in control of the environment.
- D. Encourage the patient to attend a support group such as Overeaters Anonymous.
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. Teaching stress-reduction techniques (relaxation, imagery) helps patient identify anxiety triggers leading to binge eating.
2. By recognizing anxiety, patient can interrupt pattern of mindless eating and address root cause.
3. Relaxation techniques empower patient to cope effectively without turning to food.
4. Encouraging exercise (choice B) may not directly address underlying anxiety and binge eating triggers.
5. Exploring control over the environment (choice C) does not necessarily address emotional aspects of binge eating.
6. Attending a support group (choice D) may provide peer support but doesn't focus on recognizing and reducing anxiety triggers.
The client lives so completely in a world of her own that she does not eat, drink, or bathe regularly. She is considered to be:
- A. Exotic
- B. Anorectic
- C. Neurotic
- D. Psychotic
Correct Answer: D
Rationale: The correct answer is D: Psychotic. The client's behavior of not eating, drinking, or bathing regularly indicates a severe detachment from reality, which is a hallmark of psychosis. Psychotic individuals may have delusions or hallucinations that distort their perception of the world, leading to extreme neglect of basic needs. Choices A, B, and C are incorrect because they do not specifically address the profound disconnect from reality exhibited by the client. Exotic refers to something unusual or rare, anorectic relates to an eating disorder, and neurotic typically involves anxiety and emotional instability, none of which fully capture the level of disconnection seen in psychosis.