Nokea
A newly admitted patient diagnosed with paranoid schizophrenia is hypervigilant and constantly scans the environment. He states that he saw two doctors talking in the hall and knows they were plotting to kill him. When charting, how should the nurse identify this behavior?
- A. Idea of reference
- B. Delusion of infidelity
- C. Auditory hallucination
- D. Echolalia
Correct Answer: A
Rationale: The correct answer is A: Idea of reference. This term refers to the belief that neutral events are directed at oneself. In this case, the patient's interpretation of doctors talking as a plot against him signifies a misinterpretation of reality. Delusion of infidelity (B) involves belief in a partner's unfaithfulness, which is not applicable here. Auditory hallucination (C) involves hearing voices, not relevant to this scenario. Echolalia (D) is the repetition of words spoken by others, not demonstrated in the patient's behavior. Thus, A is the most appropriate identification for this behavior.
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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.
Sensory experiences that occur in the absence of a stimulus are called
- A. illusions
- B. hallucinations
- C. delusions
- D. affect episodes
Correct Answer: B
Rationale: Hallucinations are perceptions without stimuli, distinct from illusions (misinterpretations).
A victim of spousal abuse comes to the emergency department for treatment of a broken arm. She appears hypervigilant and anxious and admits to sleep disturbance when the nurse questions the dark circles under her eyes. She reluctantly tells the nurse the abuse usually occurs when the husband has been drinking, although she concedes he is always jealous and controlling. She is a stay-at-home mother of two preschool children. The family has lived in this town for 1 month. The patient states she has fleetingly considered suicide but must stay alive to care for her children and work her way out of the abusive relationship. She denies any further suicidal thoughts. The nurse should document in the medical record that: (Select all that apply.)
- A. Signs of high anxiety and chronic stress are present.
- B. The patient relies on the perpetrator for basic needs.
- C. The patient has a history of suicidal ideation.
- D. None of the above.
Correct Answer: A
Rationale: The correct answer is A: Signs of high anxiety and chronic stress are present.
Rationale:
1. The patient displaying hypervigilance, anxiety, sleep disturbances, and dark circles under her eyes are indicators of high anxiety and chronic stress, common in victims of abuse.
2. Mentioning abuse occurring when the husband drinks, his jealousy, and control further support the presence of chronic stress and anxiety.
3. The patient's fleeting suicidal thoughts are a response to the abusive situation, not indicative of a history of suicidal ideation.
Summary:
B: The patient relying on the perpetrator for basic needs is not supported by the information provided.
C: There is no indication of a history of suicidal ideation, as the patient's thoughts are tied to her children and escaping the abusive relationship.
A nurse wants to assess for suicidal ideation in an elderly patient. Select the best question to begin this assessment.
- A. Are there any things going on in your life that would cause you to consider suicide?'
- B. What are your beliefs about a persons right to take his or her own life?'
- C. Do you think you are vulnerable to developing a depressed mood?'
- D. If you felt suicidal, would you tell someone about your feelings?'
Correct Answer: B
Rationale: This question is clear, direct, and respectful. It will produce information relative to the acceptability of suicide as an option to the patient. If the patient deems suicide unacceptable, no further assessment is necessary. If the patient deems suicide as acceptable, the nurse can continue to assess intent, plan, means to carry out the plan, lethality of the chosen method, and so forth. The other options are less direct, may produce responses that may be unclear, or are appropriate for later in this discussion.
A nurse is anxious about assessing the sexual history of a patient who is considerably older than the nurse is. Which statement would be most appropriate for obtaining information about the patient's sexual practices?
- A. Some people are not sexually active, others have a partner, and some have several partners. What has been your pattern?
- B. Sexual health can reflect a number of medical problems, so I'd like to ask if you have any sexual problems you think we should know about.
- C. It's your own business, of course, but it might be helpful for us to have some information about your sexual history. Could you tell me about that, please?
- D. I would appreciate it if you could share your sexual history with me so I can share it with your health care provider. It might be helpful in planning your treatment.
Correct Answer: A
Rationale: The correct answer is A because it acknowledges the diversity of sexual practices and respects the patient's autonomy in sharing their sexual history. It also allows the patient to openly discuss their pattern without feeling pressured.
Choice B is incorrect because it focuses on potential medical problems rather than directly asking about the patient's sexual practices.
Choice C is incorrect as it may come across as too intrusive and lacks a non-judgmental approach.
Choice D is incorrect as it implies the patient's information will be shared without their consent, which violates patient confidentiality.