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A newly admitted client has the diagnosis of catatonic schizophrenia. The nurse would expect to assess:
- A. Psychomotor symptoms
- B. Intense suspiciousness
- C. Inappropriate affect
- D. Clanging communication
Correct Answer: A
Rationale: Rationale:
A: Psychomotor symptoms are characteristic of catatonic schizophrenia, such as stupor or excessive motor activity.
B: Intense suspiciousness is more indicative of paranoid schizophrenia, not catatonic schizophrenia.
C: Inappropriate affect is a symptom seen in other types of schizophrenia but not specific to catatonic schizophrenia.
D: Clanging communication is associated with disorganized schizophrenia, not catatonic schizophrenia.
In catatonic schizophrenia, psychomotor symptoms like stupor, rigidity, or excitement are prominent.
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The nurse is planning care for a battered woman who has mentioned, 'Someday I'll have to leave him.' Which outcome should the nurse include in the plan of care for this client?
- A. Client will leave husband for a safe environment within 3 weeks
- B. Client will state that she feels more relaxed after consultation with nurse
- C. Client will state that she feels strong enough to return to the situation
- D. Client will verbalize awareness of the dangerousness of her situation
Correct Answer: D
Rationale: The correct answer is D: Client will verbalize awareness of the dangerousness of her situation. This outcome is crucial as it indicates the client's understanding of the risks involved in her current situation. By verbalizing awareness, the client is acknowledging the potential harm and taking a significant step towards recognizing the need for change. This outcome lays the foundation for further interventions and support.
Choice A is incorrect because setting a specific timeline for leaving may not be feasible or safe for the client. Choice B is incorrect as feeling relaxed does not necessarily address the underlying issue of abuse. Choice C is incorrect as feeling strong does not necessarily equate to recognizing the dangers of the situation. The focus should be on increasing awareness and empowering the client to make informed decisions.
The quality of life of people with intellectual disabilities can be improved significantly with the help of basic training procedures that will equip them with a range of skills depending on their level of disability. The application of learning theory to training in these areas is also known as:
- A. Applied cognitive approaches
- B. Applied treatment analysis
- C. Cognitive behavioural therapy
- D. Applied behaviour analysis
Correct Answer: D
Rationale: Applied Behaviour Analysis: Applying principles of learning theory, particularly operant conditioning, to improve skills in individuals with intellectual disabilities.
A patient was admitted to the mental health unit after arguing with co-workers and threatening to kill them. He is diagnosed with paranoid schizophrenia. On the unit he is aloof and suspicious. He mentioned that two physicians he saw talking were plotting to kill him. On the basis of data gathered at this point, which two primary nursing diagnoses should the nurse consider?
- A. Disturbed thought processes and Risk for other-directed violence
- B. Spiritual distress and Social isolation
- C. Risk for loneliness and Knowledge deficit
- D. Disturbed personal identity and Nonadherence
Correct Answer: A
Rationale: The correct answer is A: Disturbed thought processes and Risk for other-directed violence.
1. Disturbed thought processes: The patient's delusion of being plotted against by the physicians indicates impaired thought processes typical of paranoid schizophrenia.
2. Risk for other-directed violence: The patient's threatening behavior towards co-workers suggests a potential for violent acts towards others due to his paranoid beliefs.
Summary of why other choices are incorrect:
B: Spiritual distress and Social isolation are not primary concerns given the patient's acute symptoms of paranoia and risk for violence.
C: Risk for loneliness and Knowledge deficit are not crucial at this point as the patient's primary issues are related to paranoia and violence.
D: Disturbed personal identity and Nonadherence are not relevant to the immediate safety and mental health concerns presented by the patient.
Which intervention would be most appropriate for a patient with bulimia nervosa who is at risk for electrolyte imbalance?
- A. Offer the patient water or an electrolyte replacement solution.
- B. Encourage the patient to engage in regular physical activity.
- C. Administer a diuretic as prescribed by the physician.
- D. Withhold food to reduce the risk of further weight gain.
Correct Answer: A
Rationale: The correct answer is A: Offering the patient water or an electrolyte replacement solution. This intervention is appropriate because patients with bulimia nervosa are at risk for electrolyte imbalances due to purging behaviors. Providing water or electrolyte replacement solution helps to replenish lost electrolytes and maintain proper balance.
Option B is incorrect as excessive physical activity can further deplete electrolytes. Option C is inappropriate as administering a diuretic can worsen electrolyte imbalances. Option D is also incorrect as withholding food can exacerbate the patient's condition and increase the risk of electrolyte imbalances.
A client who was treated for anorexia nervosa is seen by the therapist for a follow-up visit 1 month after discharge from the hospital. Which statement indicates that the client has met the goal 'Demonstrate improvement in body image with more realistic view of body shape and size?'
- A. When I go shopping, I always select clothes that are several sizes too large for me.'
- B. My boyfriend says I really look good now that I'm out of the hospital.'
- C. I had my class picture taken, and I think it looks really good.'
- D. My mother bought me a whole new wardrobe since I've been home.'
Correct Answer: C
Rationale: The correct answer is C because the client's statement reflects a positive and self-affirming perception of themselves. By stating that they think their class picture looks really good, it shows an improvement in body image and a more realistic view of their body shape and size. This indicates progress towards the goal of developing a healthier self-perception.
Choice A is incorrect because selecting clothes that are several sizes too large may still indicate body image distortion and dissatisfaction. Choice B is incorrect because relying on external validation from a boyfriend does not necessarily reflect an internalized improvement in body image. Choice D is incorrect as the mother buying a new wardrobe does not directly address the client's perception of their body image or shape.