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A newly admitted patient with schizophrenia approaches the unit nurse and says, 'The voices are bothering me. They are yelling and telling me stuff. They are really bad.' Which response by the nurse would be most appropriate?
- A. Do you hear these voices very often?'
- B. Do you have a plan for getting away from the voices?'
- C. I'll stay with you. Tell me what you are hearing.'
- D. Try to ignore them and play cards with the others.'
Correct Answer: C
Rationale: The correct answer is C because it demonstrates active listening and empathy, which can help establish trust and rapport with the patient. By saying, "I'll stay with you. Tell me what you are hearing," the nurse acknowledges the patient's distress and offers support. This response can help the patient feel heard and understood, which is crucial in managing symptoms of schizophrenia.
Choice A is incorrect as it focuses more on the frequency rather than addressing the immediate distress. Choice B is incorrect as it assumes the patient has a plan to escape the voices, which may not be the case and can escalate the situation. Choice D is incorrect as it dismisses the patient's experience and suggests distraction rather than addressing the underlying issue.
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An acutely psychotic individual diagnosed with schizophreniaform disorder at admission is immediately placed on daily doses of risperidone. A hospitalization of 8 days' duration has been authorized by the HMO. By what hospital day would the nurse expect to note that client was demonstrating beginning trust in the nurse and reduction in hallucinations and delusions?
- A. Day of admission
- B. Day 3 of hospitalization
- C. Day 5 of hospitalization
- D. Day 7 of hospitalization
Correct Answer: B
Rationale: The correct answer is B: Day 3 of hospitalization. Typically, antipsychotic medications like risperidone take a few days to start showing noticeable effects in reducing hallucinations and delusions. By day 3, the medication would have had enough time to begin its therapeutic effect. Building trust with a psychotic patient also takes time, so by day 3, the patient may start showing signs of trust in the nurse. Day of admission (Choice A) is too early for the medication to take effect. Day 5 (Choice C) and Day 7 (Choice D) are too late as the medication usually shows noticeable improvement within the first few days.
A child, aged 11 years, stays home from school to care for his siblings while his mother works, because the family cannot afford a babysitter. The home is cluttered and dirty. When asked about his parents, the child reluctantly reveals that he thinks his father does not like him very much because he calls him 'stupid' and says he can never do anything right. This should be assessed as:
- A. physical abuse.
- B. sexual abuse.
- C. emotional abuse.
- D. economic abuse.
Correct Answer: C
Rationale: Explanation:
C: Emotional abuse is the correct assessment as the father's behavior of calling the child 'stupid' and criticizing him can cause psychological harm. This behavior undermines the child's self-esteem and mental well-being. The child's reluctance to speak about his parents also indicates emotional distress.
Incorrect choices:
A: Physical abuse involves causing physical harm, which is not evident in the scenario.
B: Sexual abuse involves inappropriate sexual behavior, which is not indicated in the scenario.
D: Economic abuse involves financial control or exploitation, which is not the primary issue in this scenario.
A 25-year-old individual was brought by ambulance to the emergency room. The patient's sensorium alternates between clouded and clear, and the patient becomes agitated both physically and verbally when approached. The patient's roommate states that the patient "was fine after getting up this morning but started talking crazy about 3 hours ago."Â The patient's cognitive impairment is most consistent with:
- A. delirium.
- B. dementia.
- C. sundown syndrome.
- D. early-onset Alzheimer disease.
Correct Answer: A
Rationale: The correct answer is A: delirium. Delirium is an acute change in mental status characterized by fluctuating levels of consciousness, inattention, disorganized thinking, and altered perception. In this case, the patient's clouded and clear sensorium, agitation, and recent onset of symptoms are indicative of delirium.
Choice B: dementia, is incorrect because dementia is a chronic, progressive decline in cognitive function that does not typically present with acute changes in mental status.
Choice C: sundown syndrome, is incorrect as it refers to a pattern of worsening confusion or agitation in the late afternoon or evening, not necessarily characterized by acute onset and fluctuating levels of consciousness.
Choice D: early-onset Alzheimer disease, is incorrect because Alzheimer's disease is a specific type of dementia that does not typically present with the acute and fluctuating symptoms described in the scenario.
A patient was admitted in a semistuporous catatonic state. Family states that the patient has neither left the apartment nor attended to personal hygiene for several weeks. The patient's last 48 hours have been spent lying in bed, mute and motionless. The nursing diagnosis that should be considered the priority is:
- A. self-care deficit.
- B. situational low self-esteem.
- C. disturbed thought processes.
- D. impaired verbal communication.
Correct Answer: A
Rationale: The correct answer is A: self-care deficit. The patient's symptoms indicate a lack of ability to perform self-care activities, which poses a risk to their health and well-being. This is a priority as addressing this issue will directly impact the patient's physical health and overall functioning. Situational low self-esteem (B) is not the priority as it focuses on the patient's emotional state rather than their immediate physical needs. Disturbed thought processes (C) and impaired verbal communication (D) may be present but are not the priority over the patient's inability to perform self-care activities.
The nurse is working with a patient diagnosed with bulimia nervosa. Which assessment is most important?
- A. Monitor electrolyte levels and cardiac function.
- B. Observe for compulsive eating behaviors.
- C. Track the patient's ability to self-regulate food intake.
- D. Assess for symptoms of depression and anxiety.
Correct Answer: A
Rationale: The correct answer is A because patients with bulimia nervosa are at risk for electrolyte imbalances and cardiac issues due to purging behaviors. Monitoring electrolyte levels and cardiac function is crucial for early detection and intervention. Option B is incorrect as it focuses on behaviors rather than potential medical complications. Option C is less critical than monitoring electrolytes and cardiac function. Option D, although important, is not as immediately critical as monitoring electrolyte levels and cardiac function in this context.