Nokea
A nurse is caring for a client who has schizophrenia. The client states, "The government is forcing thoughts into my brain through satellites." The nurse should document that the client is experiencing which of the following types of delusions?
- A. Persecution
- B. Erotomanic
- C. Somatic
Correct Answer: A
Rationale: Persecutory delusions involve irrational beliefs that one is being targeted or harmed by external forces.
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A nurse is providing teaching for a client who has binge-eating disorder and is morbidly obese. The client has been prescribed orlistat. Which of the following statements indicates to the nurse that the client understands the teaching?
- A. "I will take my dose of orlistat every morning an hour before breakfast."
- B. "I will stop taking orlistat and call my doctor if my urine gets darker in color."
- C. "I will eat a no-fat diet to prevent side effects from the medication."
- D. "I will feel less hungry during meals while I am taking orlistat."
Correct Answer: B
Rationale: The correct answer is B: "I will stop taking orlistat and call my doctor if my urine gets darker in color." This statement indicates understanding because dark urine can be a sign of liver injury, a serious side effect of orlistat. The client recognizing this symptom and knowing to contact the doctor promptly demonstrates comprehension of the medication's potential risks.
A: "I will take my dose of orlistat every morning an hour before breakfast." - This statement does not indicate understanding of the medication's specific instructions.
C: "I will eat a no-fat diet to prevent side effects from the medication." - While a low-fat diet is recommended with orlistat, this statement does not address potential serious side effects.
D: "I will feel less hungry during meals while I am taking orlistat." - This statement does not address the medication's side effects or potential risks.
A nurse is assessing an adolescent female client who has anorexia nervosa. Which of the following findings should the nurse expect?
- A. Tachycardia
- B. Constipation
- C. Menorrhagia
- D. Hyperkalemia
Correct Answer: B
Rationale: The correct answer is B: Constipation. In anorexia nervosa, a lack of adequate nutrition intake can lead to decreased gastrointestinal motility, resulting in constipation. Tachycardia (A) is common due to the body's response to malnutrition. Menorrhagia (C) is unlikely as anorexia nervosa often leads to amenorrhea. Hyperkalemia (D) is less likely as potassium levels tend to be low due to decreased food intake.
A nurse in a mental health clinic is conducting a staff education session on schizophrenia. Which of the following manifestations should the nurse identify as negative symptoms? (Select all that apply.)
- A. Delusions
- B. Hallucinations
- C. Anhedonia
- D. Poor judgment
- E. Blunt affect
Correct Answer: C, E
Rationale: The correct manifestations for negative symptoms of schizophrenia are C: Anhedonia and E: Blunt affect. Anhedonia refers to the inability to feel pleasure, which is a common negative symptom. Blunt affect is a reduction in the range and intensity of emotional expression, another classic negative symptom. Delusions (A) and hallucinations (B) are positive symptoms involving distorted perceptions and beliefs. Poor judgment (D) is a cognitive symptom, not specific to schizophrenia. The absence of options F and G means they are not applicable to this question.
A nurse is caring for an older adult client who had a cerebrovascular accident and has right-sided paralysis and aphasia. The client's son tells the nurse it is his fault because he did not insist that his mother live with him. Which of the following responses should the nurse make?
- A. "So, it seems that you feel responsible for what happened to your mother."
- B. "Your mother will be fine. You shouldn't worry so much."
- C. "Why do you blame yourself? You could not have prevented the stroke."
- D. "You are not responsible for your mother's stroke, but many people in your situation feel this way."
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
A is the correct response because it acknowledges the son's feelings without dismissing or invalidating them. It shows empathy and understanding towards his guilt, opening up a conversation for further exploration of his emotions. It reflects active listening and validates his concerns.
Summary of Incorrect Choices:
B: This response minimizes the son's feelings and does not address his sense of guilt, which can further exacerbate his emotional distress.
C: While this response provides reassurance, it does not address the son's feelings of guilt and may come off as dismissive.
D: This response acknowledges the son's feelings but does not directly validate his sense of responsibility, missing an opportunity for therapeutic communication.
A nurse is caring for a client who has a new diagnosis of human immunodeficiency virus (HIV). He states, "I don't care what the doctors say, there is no way I can have HIV, and I don't need treatment for something I don't have." The nurse identifies that the client is experiencing which of the following types of crisis?
- A. Adventitious
- B. Internal
- C. Maturational
- D. Situational
Correct Answer: D
Rationale: The correct answer is D: Situational crisis. The client's denial of the HIV diagnosis and refusal of treatment indicate an acute crisis triggered by a specific event or situation - the new HIV diagnosis. In a situational crisis, individuals struggle to cope with a sudden and unexpected event, leading to cognitive dissonance and emotional distress. The client's disbelief and avoidance of the reality of the diagnosis demonstrate a maladaptive response to the crisis. Adventitious crisis (A) refers to events like natural disasters, which are not applicable here. Internal crisis (B) involves inner conflicts, not evident in this scenario. Maturational crisis (C) arises from developmental life stages, which is not the case here.