Nokea
A normal person sees flashes of light while falling asleep. These are examples of
- A. Hypnopompic hallucinations
- B. Eidetic imagery
- C. Visual hallucinations
- D. Complex hallucinations
Correct Answer: C
Rationale: Flashes of light while falling asleep are hypnagogic visual hallucinations, a normal phenomenon, though 'visual hallucinations' is the closest match here.
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Which statement by a patient with bulimia nervosa suggests the need for further education?
- A. I understand that purging is harmful to my health.
- B. I have learned to control my binge eating episodes.
- C. I feel that I can continue purging occasionally without harm.
- D. I know that therapy can help me change my eating behaviors.
Correct Answer: C
Rationale: The correct answer is C because it indicates a lack of awareness about the harmful consequences of purging. The statement suggests a rationalization of continuing the harmful behavior, showing a need for further education on the risks associated with purging. Choice A demonstrates understanding of the harm, B shows progress in controlling binge eating, and D acknowledges the potential benefits of therapy. Educating the patient about the dangers of purging is crucial in addressing their condition effectively.
In a sad voice, an elderly patient tells the nurse of the recent deaths of a spouse and close friend. The patient has no other family and only a few acquaintances in the community. The nurse's priority is to determine whether which nursing diagnosis applies to this patient?
- A. Risk for suicide related to recent deaths of significant others
- B. Anxiety related to sudden and abrupt lifestyle changes
- C. Social isolation related to loss of existing family
- D. Spiritual distress related to anger with God
Correct Answer: A
Rationale: The correct answer is A: Risk for suicide related to recent deaths of significant others. This is the priority because the patient's recent losses put them at high risk for suicide. The nurse must assess the patient's risk level and provide appropriate interventions to prevent harm. Choices B, C, and D are incorrect because anxiety and social isolation are secondary concerns compared to the immediate risk of suicide. Spiritual distress, while important, does not take precedence over the patient's safety.
The nurse notes that a male client, who is taking an antipsychotic medication, is constantly moving from chair to chair during a group activity, and he complains that he feels 'nervous and jittery inside.' The nurse is aware that this client most likely is experiencing:
- A. Akinesia
- B. Dystonia
- C. Dyskinesia
- D. Akathisia
Correct Answer: D
Rationale: The correct answer is D: Akathisia. Akathisia is a common side effect of antipsychotic medications characterized by restlessness, inability to sit still, and a feeling of inner restlessness or jitteriness. In this case, the client's constant movement and feeling of nervousness align with the symptoms of akathisia.
A: Akinesia is the opposite of what the client is experiencing, characterized by a lack of movement or muscle weakness.
B: Dystonia involves involuntary muscle contractions and abnormal postures, not constant movement.
C: Dyskinesia refers to abnormal, involuntary movements of the face, trunk, and limbs, which are not described in the scenario.
The nurse is leading a group for women who have experienced interpersonal violence. A client asks what research statistics tell about the perpetrators of interpersonal violence. The nurse can accurately respond that perpetrators are:
- A. Usually under the influence of drugs or alcohol
- B. Most often someone the victim knows
- C. A stranger to the victim in most cases
- D. Often in a psychotic state during the act
Correct Answer: B
Rationale: The correct answer is B because research shows that perpetrators of interpersonal violence are most often someone the victim knows, such as a partner, family member, or acquaintance. This is supported by studies and data that indicate a significant majority of interpersonal violence cases involve perpetrators who have a prior relationship with the victim. Choice A is incorrect because while substance abuse can be a factor in some cases, it is not the primary characteristic of perpetrators. Choice C is incorrect as statistics show that perpetrators are usually known to the victim rather than being strangers. Choice D is also incorrect as psychotic states are not typically the primary cause of interpersonal violence, and most perpetrators are not in such a state during the act.
A victim of rape says, "My family is not very supportive."Â Which belief contributes to a negative family response?
- A. No one asks to be raped.
- B. Rape is an act of aggression.
- C. Rape should not be discussed.
- D. Anyone is a potential rape victim.
Correct Answer: C
Rationale: The correct answer is C: Rape should not be discussed. This belief contributes to a negative family response because it promotes silence and stigma around the topic of rape, leading to lack of support and understanding for the victim. By not discussing rape, the victim may feel isolated, ashamed, and unable to seek help or share their experience. Choices A and B are incorrect as they acknowledge the victim's innocence and the violent nature of rape. Choice D is incorrect as it recognizes the reality that anyone can be a victim, but it does not directly address the issue of discussing rape within the family.