Nokea
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 because the patient's behavior indicates a possible experience of auditory hallucinations. The patient covering both ears and shaking her head could be an attempt to block out voices or sounds she is hearing. The subsequent crying and muttering could be a response to these hallucinations.
Choice A is incorrect because the patient's behavior does not necessarily indicate a desire for attention. Choice B is incorrect because the patient's emotional expression is not the primary focus of the behavior. Choice D is incorrect because negative symptoms of schizophrenia typically involve a decrease in emotional expression or motivation, which is not evident in this scenario.
You may also like to solve these questions
The wife of a client diagnosed with paranoid schizophrenia asks, 'I've been told that my husband's illness is probably related to imbalanced brain chemicals. Can you be more specific?' The response based on the dopamine hypothesis is:
- A. An increase in the brain chemical dopamine explains the presence of delusions and hallucinations.'
- B. An increase in the brain chemical dopamine explains the presence of lack of motivation and disordered affect.'
- C. Decreased amounts of the brain chemical dopamine explain the presence of delusions and hallucinations.'
- D. Breakdown of dopamine produces LSD, which in large amounts produces psychosis.'
Correct Answer: A
Rationale: Step-By-Step Rationale:
1. The dopamine hypothesis states that an increase in dopamine is linked to delusions and hallucinations in schizophrenia.
2. Delusions and hallucinations are common positive symptoms of schizophrenia.
3. Therefore, choice A is correct as it directly aligns with the dopamine hypothesis and the symptoms observed in paranoid schizophrenia.
Summary of Incorrect Choices:
B. Incorrect because an increase in dopamine is not typically associated with lack of motivation and disordered affect in schizophrenia.
C. Incorrect because decreased amounts of dopamine are not linked to delusions and hallucinations in schizophrenia.
D. Incorrect because the breakdown of dopamine producing LSD and causing psychosis is not supported by the dopamine hypothesis in schizophrenia.
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.
A nursing diagnosis for a patient with bulimia nervosa is Ineffective coping related to feelings of loneliness and isolation, as evidenced by use of overeating and self-induced vomiting to comfort self. Select the best outcome related to this diagnosis. Within 2 weeks, the patient will:
- A. appropriately express angry feelings.
- B. verbalize two positive things about self.
- C. verbalize the importance of eating a balanced diet.
- D. identify two alternative methods of coping with loneliness and isolation.
Correct Answer: D
Rationale: The correct answer is D because it directly addresses the nursing diagnosis of ineffective coping related to feelings of loneliness and isolation. By identifying two alternative methods of coping, the patient can develop healthier strategies to manage these emotions instead of resorting to overeating and vomiting. This outcome promotes long-term behavioral change and helps the patient build resilience.
Choice A is incorrect because expressing angry feelings may not necessarily address the underlying issues of loneliness and isolation. Choice B is incorrect as verbalizing positive things about oneself may be beneficial but does not directly address coping mechanisms for loneliness and isolation. Choice C is also incorrect because understanding the importance of a balanced diet does not directly address coping strategies for managing emotions like loneliness and isolation.
A man who reports frequently experiencing premature ejaculation tells the nurse, 'I feel like such a failure. It's so awful for both me and my partner. Can you help me?' Select the nurse's best response.
- A. Have you discussed this problem with your partner?
- B. I can refer you to a practitioner who can help you with this problem.
- C. Have you asked your health care provider for prescription medication?
- D. There are several techniques described in this pamphlet that might be helpful.
Correct Answer: B
Rationale: The correct answer is B because the nurse should refer the patient to a practitioner who specializes in treating premature ejaculation. This is the best response as it ensures the patient receives specialized care and treatment tailored to his needs. Referring to a specialist increases the likelihood of successful intervention and addresses the patient's concerns effectively.
Choices A, C, and D are incorrect. Choice A focuses on communication with the partner, which is important but not the primary intervention for premature ejaculation. Choice C suggests prescription medication without exploring other treatment options or assessing the patient's individual situation. Choice D provides general information without addressing the patient's emotional distress or offering specific help from a professional.
When screening families for post-traumatic stress disorder following a major natural disaster, psychiatric-mental health nurses are practicing which type of disease prevention?
- A. Primary
- B. Secondary
- C. Tertiary
- D. Universal
Correct Answer: B
Rationale: Secondary prevention involves early detection (screening) to mitigate PTSD after exposure, unlike primary (prevention) or tertiary (rehabilitation).