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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.
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The physician prescribes haloperidol (Haldol), a first-generation antipsychotic drug, for a patient with schizophrenia who displays delusions, hallucinations, apathy, and social isolation. Which symptoms should most be monitored to evaluate the expected improvement from this medication?
- A. Talking to himself, belief that others will harm him
- B. Flat affect, avoidance of social activities, poor hygiene
- C. Loss of interest in recreational activities, alogia
- D. Impaired eye contact, needs help to complete tasks
Correct Answer: A
Rationale: The correct answer is A because haloperidol is primarily used to target positive symptoms of schizophrenia such as delusions and hallucinations. Monitoring improvements in symptoms like talking to himself and belief that others will harm him will indicate the effectiveness of the medication. Choices B, C, and D are incorrect because they focus on negative symptoms or general social withdrawal, which are less likely to show significant improvement with haloperidol, a first-generation antipsychotic drug that is more effective for positive symptoms. Monitoring these symptoms may not directly reflect the medication's effectiveness in treating the primary symptoms of schizophrenia in this case.
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.
A 25-year-old individual was brought by ambulance to the emergency room. The patient's sensorium alternates between clouded and clear, and the patient becomes agitated both physically and verbally when approached. The patient's roommate states that the patient "was fine after getting up this morning but started talking crazy about 3 hours ago."Â The patient's cognitive impairment is most consistent with:
- A. delirium.
- B. dementia.
- C. sundown syndrome.
- D. early-onset Alzheimer disease.
Correct Answer: A
Rationale: The correct answer is A: delirium. Delirium is an acute change in mental status characterized by fluctuating levels of consciousness, inattention, disorganized thinking, and altered perception. In this case, the patient's clouded and clear sensorium, agitation, and recent onset of symptoms are indicative of delirium.
Choice B: dementia, is incorrect because dementia is a chronic, progressive decline in cognitive function that does not typically present with acute changes in mental status.
Choice C: sundown syndrome, is incorrect as it refers to a pattern of worsening confusion or agitation in the late afternoon or evening, not necessarily characterized by acute onset and fluctuating levels of consciousness.
Choice D: early-onset Alzheimer disease, is incorrect because Alzheimer's disease is a specific type of dementia that does not typically present with the acute and fluctuating symptoms described in the scenario.
The nurse is working with a patient diagnosed with bulimia nervosa. Which assessment is most important?
- A. Monitor electrolyte levels and cardiac function.
- B. Observe for compulsive eating behaviors.
- C. Track the patient's ability to self-regulate food intake.
- D. Assess for symptoms of depression and anxiety.
Correct Answer: A
Rationale: The correct answer is A because patients with bulimia nervosa are at risk for electrolyte imbalances and cardiac issues due to purging behaviors. Monitoring electrolyte levels and cardiac function is crucial for early detection and intervention. Option B is incorrect as it focuses on behaviors rather than potential medical complications. Option C is less critical than monitoring electrolytes and cardiac function. Option D, although important, is not as immediately critical as monitoring electrolyte levels and cardiac function in this context.
A client tried to gouge out his eye in response to auditory hallucinations commanding, 'If thine eye offend thee, pluck it out.' The nurse would analyze this behavior as indicating:
- A. Impaired impulse control
- B. Inability to manage anger
- C. Derealization
- D. Inappropriate affect
Correct Answer: A
Rationale: The correct answer is A: Impaired impulse control. This behavior shows a lack of control over impulsive actions, as the client acted immediately on the auditory hallucination without considering the consequences. Choice B is incorrect because anger management is not directly related here. Choice C, derealization, refers to feeling disconnected from reality, which is not evident in the scenario. Choice D, inappropriate affect, does not fit as the client's action is more about impulsivity than emotional expression. Ultimately, the client's behavior aligns most closely with impaired impulse control due to the immediate and extreme response to the auditory hallucination.