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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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A client displays disorganized thinking, difficult-to-follow speech, and silly, inappropriate affect. The client isolates himself from other clients and staff, ignores unit activities, and often seems to be listening and responding to unseen stimuli. This client's behavior most closely conforms to the characteristic behavior of:
- A. Residual schizophrenia
- B. Schizoaffective disorder
- C. Paranoid schizophrenia
- D. Disorganized schizophrenia
Correct Answer: D
Rationale: The correct answer is D: Disorganized schizophrenia. This client's presentation aligns with the symptoms of disorganized schizophrenia, characterized by disorganized thinking, speech, and behavior, inappropriate affect, social withdrawal, and hallucinations. Residual schizophrenia (A) refers to a milder form of schizophrenia with lingering symptoms. Schizoaffective disorder (B) involves symptoms of both schizophrenia and mood disorders. Paranoid schizophrenia (C) is characterized by delusions and auditory hallucinations, which are not the primary symptoms displayed by the client in the question.
A client frequently impulsively acts out suicidal impulses, including grabbing the coffee jar to smash it and attempting to hang herself with her bra. The nurse would view the client's behaviors as most consistent with:
- A. Narcissistic personality disorder
- B. Histrionic personality disorder
- C. Borderline personality disorder
- D. Antisocial personality disorder
Correct Answer: C
Rationale: The correct answer is C: Borderline personality disorder. The client's impulsive and self-destructive behaviors, such as attempting suicide, are characteristic of individuals with borderline personality disorder. These individuals often struggle with intense emotions, unstable relationships, and have a fear of abandonment. They may engage in self-harming behaviors as a way to cope with emotional distress.
A: Narcissistic personality disorder is characterized by a grandiose sense of self-importance and a lack of empathy. This does not align with the impulsive and self-destructive behaviors described in the scenario.
B: Histrionic personality disorder is characterized by attention-seeking behaviors and excessive emotions. While there may be some overlap with impulsive behaviors, it does not fully capture the severity and self-destructiveness of the client's actions.
D: Antisocial personality disorder is characterized by a disregard for the rights of others and a lack of remorse. While individuals with this disorder may engage in impulsive behaviors, the specific behaviors described in
A women who is 16 weeks pregnant presents with symptoms suggestive of a urinary tract infection. Which one of the following is correct?
- A. She should be assured that urinary tract infections are common in pregnancy and require no treatment.
- B. A midstream urine should be collected and the bacteriology report awaited.
- C. A midstream urine should be collected and a wide spectrum antibiotic prescribed.
- D. A self-retaining catheter should be introduced to promote free drainage of urine.
Correct Answer: C
Rationale: In pregnancy, UTIs require prompt treatment due to risks like pyelonephritis. Collecting a midstream urine and starting a broad-spectrum antibiotic (C) is standard, pending culture results. Ignoring treatment (A), waiting without antibiotics (B), or invasive measures (D, E) are inappropriate.
An 82-year-old widow with Alzheimer's disease lives with her daughter's family, which owns a catering business. During the week, the patient attends a daycare center for patients. During the evenings, members of the family care for the patient. One day, the nurse at the daycare center notices the patient's appearance is disheveled and that she has bruises on her wrists and back when escorted to the bathroom. What most likely explains the nurse's observations?
- A. The patient is being neglected and abused within the family.
- B. The dementia is progressing, reducing self-care and increasing falls.
- C. The patient is experiencing normal aging symptoms.
- D. The patient is suffering from a new medical condition.
Correct Answer: A
Rationale: The correct answer is A because the nurse's observations of disheveled appearance, bruises, and signs of physical abuse indicate possible neglect and abuse within the family. This is supported by the presence of Alzheimer's disease, vulnerability due to age, and the patient's living situation with family members who own a catering business. Choice B is incorrect as it does not explain the bruises and neglect observed. Choice C is incorrect as normal aging symptoms would not typically include bruises and neglect. Choice D is incorrect as there is no indication of a new medical condition causing these specific observations.
The nurse is caring for a patient with anorexia nervosa. Which intervention is a priority?
- A. Establish a no-contact rule with the patient's family.
- B. Monitor the patient's food intake and weight closely.
- C. Encourage the patient to exercise to improve health.
- D. Focus primarily on addressing the patient's body image issues.
Correct Answer: B
Rationale: The correct answer is B because monitoring food intake and weight closely is crucial in managing anorexia nervosa to prevent further complications like malnutrition and dehydration. By closely monitoring these factors, the nurse can ensure the patient is receiving adequate nutrition and is not losing weight rapidly. Establishing a no-contact rule with the family (A) could hinder the patient's support system. Encouraging exercise (C) may worsen excessive calorie expenditure. Focusing on body image (D) is important but addressing immediate health risks takes precedence.