Nokea
A nurse is caring for a client diagnosed with schizophrenia. The client states,Did you know that I am engaged to the Prince of England? The nurse should document that the client is experiencing which of the following types of delusions?
- A. Persecution
- B. Erotomanic
- C. Somatic
- D. Control
Correct Answer: B
Rationale: The correct answer is B: Erotomanic delusion. This type of delusion involves the false belief that someone, typically of higher status or unreachable, is in love with the individual. In this case, the client believes they are engaged to the Prince of England, indicating an erotomanic delusion. Choice A: Persecution delusion involves believing one is being targeted or mistreated. Choice C: Somatic delusion involves beliefs about bodily functions. Choice D: Control delusion involves beliefs about external control. These are not applicable in the scenario described.
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A nurse is teaching the parent of an adolescent who was recently diagnosed with oppositional defiant disorder (ODD). The parent asks,Is there a medication that can help my child? Which of the following responses should the nurse make?
- A. Medication is usually not prescribed to treat oppositional defiant disorder. Let's discuss some behavioral strategies you can use.
- B. There are many medications that will help your child manage aggression and destructiveness. The health care provider will discuss them with you.
- C. Medication is not used to treat this oppositional defiant disorder because it is behavioral in nature.
- D. It's a common misconception that there is a medication available to treat every health problem.
Correct Answer: A
Rationale: The correct answer is A: Medication is usually not prescribed to treat oppositional defiant disorder. Let's discuss some behavioral strategies you can use. ODD is primarily a behavioral disorder, not a chemical imbalance, so medication is not typically the first-line treatment. Behavioral strategies such as cognitive-behavioral therapy, parent training, and family therapy are more effective in managing ODD symptoms. Other choices are incorrect because they either suggest medication as the primary treatment without acknowledging the behavioral aspect of ODD (B), state inaccuracies about medication use for ODD (C), or divert the conversation away from addressing the parent's concerns (D).
What treatment is commonly used for aggressive behavior disorder?
- A. Hypnosis
- B. Cognitive-behavioral therapy (CBT)
- C. Medication
- D. Physical restraint
Correct Answer: B
Rationale: The correct answer is B: Cognitive-behavioral therapy (CBT). CBT is effective for aggressive behavior disorder as it helps individuals identify and change negative thought patterns and behaviors that contribute to aggression. It teaches coping skills and problem-solving techniques to manage anger and impulses. Hypnosis (A) is not typically used for aggressive behavior. Medication (C) may be prescribed in some cases, but it is often used in conjunction with therapy. Physical restraint (D) is a last resort and not a primary treatment for aggressive behavior.
A male client is admitted to the unit with a possible diagnosis of delirium. Which statement by the client's wife best supports the diagnosis?
- A. Since his mother died, he has not been feeling well.
- B. My husband just didn't seem to know what he was doing. He has been forgetful for years.
- C. The changes in his behavior came on so quickly! I wasn't sure what was happening.
- D. This is supposed to happen when you get old, right?
Correct Answer: C
Rationale: The correct answer is C because delirium is characterized by a rapid onset of confusion, changes in behavior, and altered mental status. The wife's statement about the changes in behavior coming on quickly aligns with this key characteristic of delirium.
Choice A is incorrect because the client's feelings after his mother's death are not necessarily related to delirium. Choice B is incorrect because long-term forgetfulness is more indicative of dementia rather than delirium. Choice D is incorrect because delirium is not a normal part of aging.
A nurse is teaching a female client who has an anxiety disorder and is prescribed alprazolam (Xanax). Which of the following information should the nurse include in the teaching?
- A. If a dose is missed, do not double the next dose of medication.
- B. This medication may cause dizziness upon standing.
- C. Use a dependable form of contraception while taking this medication.
- D. Do not drink alcohol while taking this medication.
Correct Answer: B
Rationale: The correct answer is B: This medication may cause dizziness upon standing. Alprazolam is a benzodiazepine that can cause dizziness as a side effect, especially when standing up quickly. This information is important for the client to prevent falls or accidents.
A: Missing a dose should not be addressed by doubling the next dose as it can lead to overdose or adverse effects.
C: Although contraceptives might be important to discuss, it is not specifically related to the medication itself.
D: Alcohol should be avoided while taking alprazolam due to the increased risk of side effects and potential interactions, but it is not the most crucial information for the client's safety.
The nurse is teaching a client about cellular hypertrophy. Which statement should be included in the teaching?
- A. It's uncontrolled proliferative cell growth that is cancerous.
- B. It's the enlargement of an organ or tissue from the increase in cell size.
- C. It's the wasting away of tissue or organs.
- D. It's the abnormal growth or development of cells.
Correct Answer: B
Rationale: The correct answer is B because cellular hypertrophy refers to the increase in the size of cells leading to the enlargement of an organ or tissue. This is a normal physiological response to increased demand or stress. Choice A is incorrect as uncontrolled proliferative cell growth leading to cancer is known as neoplasia, not hypertrophy. Choice C is incorrect as wasting away of tissue is termed as atrophy, not hypertrophy. Choice D is incorrect as abnormal cell growth or development is more indicative of dysplasia or metaplasia, not hypertrophy.