Nokea
A hospitalized client sees snakes on the walls of the hospital room and becomes anxious. This is an example of which of the following?
- A. Hallucinations
- B. Delirium
- C. Delusion
- D. Psychosis
Correct Answer: A
Rationale: Hallucinations involve perceiving things that aren’t present, like seeing snakes, fitting the client’s experience. Delirium is a broader state of confusion that may include hallucinations but isn’t specific to this symptom alone. Delusions are false beliefs, not perceptions. Psychosis is a general term that can include hallucinations but isn’t as precise as the specific symptom described.
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A client describes flashbacks of a terrifying car crash in which he saw his best friend die. Which disorder should the nurse suspect in this situation?
- A. Panic disorder
- B. Obsessive-compulsive disorder
- C. Posttraumatic stress disorder
- D. Agoraphobia
Correct Answer: C
Rationale: Panic disorder involves unexpected and repeated episodes of intense fear, often without a specific trigger, and isn’t typically linked to flashbacks. Obsessive-compulsive disorder is characterized by unwanted repeated thoughts (obsessions) and actions (compulsions), not trauma-related flashbacks. PTSD involves re-experiencing a traumatic event through flashbacks and nightmares, directly matching the client’s symptoms of reliving the car crash. Agoraphobia is an anxiety disorder involving fear of places or situations that might cause panic, not tied to specific traumatic memories.
A client is given the diagnosis of generalized anxiety disorder and is prescribed a benzodiazepine. The client should be instructed on which of the following?
- A. Monthly laboratory tests are needed to monitor drug level.
- B. Foods that contain tyramine should be avoided
- C. Benzodiazepines do not cause physical dependence.
- D. Benzodiazepines and alcohol can be dangerous
Correct Answer: D
Rationale: Lab tests aren’t routine for benzodiazepines. Tyramine avoidance applies to MAOIs, not benzodiazepines. Benzodiazepines can cause dependence, so that’s false. Combining benzodiazepines with alcohol increases CNS depression, posing risks like respiratory failure, making it critical to instruct the client on this danger.
A nurse is conducting a home health visit for an older adult client who lives with family members. The nurse notices that the client has multiple unusual bruises, and, based on several other factors, the nurse suspects that the client has been physically abused. Which of the following actions should the nurse take first?
- A. Check the bruises at the next visit to the client's home.
- B. Institute more frequent visits to the client's home.
- C. Follow the agency's guidelines for reporting suspected abuse.
- D. Arrange referral for family therapy to deal with home stressors.
Correct Answer: C
Rationale: Delaying action by checking bruises later doesn’t address immediate safety. More frequent visits monitor but don’t act on the suspicion promptly. Following agency guidelines for reporting suspected abuse ensures the client’s safety first, as it’s the nurse’s legal and ethical duty. Therapy may help later but isn’t the first step without ensuring safety.
A client with Alzheimer's disease has difficulty with bathing and dressing activities. This is an example of which type of loss?
- A. Physical loss
- B. Functional loss
- C. Affective loss
- D. Conative loss
Correct Answer: B
Rationale: Physical loss involves losing a body part or function, not the ability to perform tasks. Functional loss is the reduced ability to perform daily activities like bathing and dressing, common in Alzheimer’s due to cognitive and motor decline. Affective loss is emotional, and conative loss relates to motivation, neither fitting this scenario.
In developing a nursing care plan for an adult with a mental health disorder, the nurse knows the goals that are set must be:
- A. Important to the client
- B. Evaluated on a weekly basis
- C. Achievable by client discharge
- D. Approved by the physician
Correct Answer: A
Rationale: Client-important goals boost engagement. Weekly evaluation is useful but not mandatory. Discharge-tied goals may not fit long-term needs. Physician approval is secondary to client-centered planning.