Nokea
A nurse caring for a patient with Alzheimer disease can anticipate that the family will most likely need information about:
- A. antimetabolites.
- B. benzodiazepines.
- C. immunosuppressants.
- D. acetylcholinesterase inhibitors.
Correct Answer: D
Rationale: The correct answer is D: acetylcholinesterase inhibitors. Patients with Alzheimer's disease often benefit from this type of medication to help improve cognitive function. The family would need information on this to understand the treatment plan. Antimetabolites (A), benzodiazepines (B), and immunosuppressants (C) are not typically used in the treatment of Alzheimer's disease and would not be relevant for the family to know about in this context.
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A nurse observes a patient who is sitting alone in a room put hands over both ears and vigorously shake her head as though saying, 'No.' Later the patient cries and mutters, 'You don't know what you're talking about! Leave me alone.' What assessment should the nurse attempt to validate?
- A. The patient is seeking the attention of staff.
- B. The patient is inappropriately expressing emotion.
- C. The patient is experiencing auditory hallucinations.
- D. The patient is displaying negative symptoms of schizophrenia.
Correct Answer: C
Rationale: The correct answer is C: The patient is experiencing auditory hallucinations. The patient's behavior of covering both ears and shaking her head as if responding to voices, along with muttering and crying, suggests a sensory perception that is not based on external stimuli. This aligns with the characteristic symptoms of auditory hallucinations, which are common in conditions like schizophrenia.
Choice A is incorrect because the patient's behavior is not necessarily seeking attention but rather responding to internal stimuli. Choice B is incorrect as the patient's emotional expression seems to be a result of the auditory hallucinations rather than being inappropriate. Choice D is incorrect as negative symptoms of schizophrenia typically involve a decrease or absence of normal functions, which is not clearly demonstrated in this scenario.
A client tells the nurse, 'I hear people whispering about me. When I'm in the day room and they do that, I want to punch them.' The information the nurse should give to staff in report consists of which of the following?
- A. Treat this client matter-of-factly. Be direct; don't talk about him or others in his presence.'
- B. Stay away from this client. The fewer interactions you have with him, the fewer misinterpretations there will be.'
- C. Stay close to this client and use touch as you interact with him.'
- D. To help him become less anxious with whispering, speak in a very soft voice when you are near him.'
Correct Answer: A
Rationale: The correct answer is A: "Treat this client matter-of-factly. Be direct; don't talk about him or others in his presence." This response is appropriate because it emphasizes the importance of respecting the client's privacy and dignity by not discussing him or others in his presence. By being direct and matter-of-fact, the nurse can establish trust and build a therapeutic relationship with the client. This approach also helps maintain boundaries and avoids escalating the situation.
Choice B is incorrect because avoiding the client may lead to feelings of rejection and worsen his symptoms. Choice C is incorrect because using touch without the client's consent may be inappropriate and could escalate the situation. Choice D is incorrect because speaking softly does not address the underlying issue of the client feeling threatened by whispering.
When making a distinction as to whether an elderly patient has confusion related to delirium or another problem, what information would be of particular value?
- A. Evidence of spasticity or flaccidity
- B. The patients level of motor activity
- C. Medications the patient has recently taken
- D. Level of preoccupation with somatic symptoms
Correct Answer: C
Rationale: Delirium in the elderly produces symptoms of confusion. Medication interactions or adverse reactions are often a cause. The distracters do not give information important for delirium.
The home care nurse assessed a client with a history of dementia who had a herniorrhaphy at an ambulatory surgical center the previous day. The client lives in a senior living facility. The client thinks he is in the army and that it is 1945. The nurse should:
- A. Reorient the client to the current time and place.
- B. Notify the client's family of the confusion.
- C. Document the client's confusion and disorientation.
- D. None of the above.
Correct Answer: A
Rationale: The correct answer is A: Reorient the client to the current time and place. The nurse should reorient the client to prevent distress and promote safety. This approach helps the client feel more secure and may reduce confusion. Choice B is incorrect because the nurse should address the client's needs first. Choice C is not enough on its own as the nurse needs to actively assist the client. Choice D is incorrect as action is needed in this situation to support the client.
A client who is diagnosed with schizoid personality disorder is isolative, does not speak to her peers, and sits through the community meeting without speaking. Her mother describes her as shy and having few friends. Which would be an appropriate nursing diagnosis for this client?
- A. Anxiety related to a new environment as evidenced by isolation and not talking with peers
- B. Impaired social interaction related to unfamiliar environment as evidenced by isolation and not talking with peers
- C. Ineffective coping related to new environment as evidenced by isolation and minimal interaction with others
- D. Disturbed thought processes related to a new environment as evidenced by isolation and minimal interactions with others
Correct Answer: B
Rationale: The correct answer is B: Impaired social interaction related to unfamiliar environment as evidenced by isolation and not talking with peers. This is the most appropriate nursing diagnosis for the client because it accurately reflects the client's behavior of isolation and lack of communication with peers, which are indicative of impaired social interaction.
Rationale:
1. Impaired social interaction is a key characteristic of schizoid personality disorder, as individuals with this disorder tend to be socially isolated and have difficulty forming relationships.
2. The client's behavior of not speaking to peers and sitting through meetings without interaction supports the diagnosis of impaired social interaction.
3. The description of the client by her mother as shy and having few friends further supports the diagnosis of impaired social interaction.
Summary:
A: Anxiety related to a new environment is incorrect because the client's behavior is more indicative of impaired social interaction rather than anxiety.
C: Ineffective coping related to new environment is incorrect as there is no evidence to suggest that the client is using maladaptive coping