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A nurse would attempt to reduce nighttime agitation for a patient with either delirium or dementia by:
- A. giving warm milk as a snack at bedtime.
- B. keeping a soft light on in the patient's room.
- C. placing a large-faced lighted alarm clock opposite the bed.
- D. hanging family pictures near enough to the bed to be easily seen.
Correct Answer: B
Rationale: The correct answer is B: keeping a soft light on in the patient's room. This helps to reduce nighttime agitation by providing a soothing environment without complete darkness, which can cause confusion and disorientation in patients with delirium or dementia. Warm milk (A) may not address the underlying cause of agitation. A large-faced lighted alarm clock (C) may be distracting and increase confusion. Family pictures (D) may not directly impact nighttime agitation and could potentially overstimulate the patient.
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Disturbed body image is the nursing diagnosis for a patient with an eating disorder. Which outcome indicator is most applicable to this diagnosis?
- A. Weight, muscle, and fat congruence with height, frame, age, and sex.
- B. Calorie intake within required parameters of treatment plan.
- C. Weight at established normal range for the patient.
- D. None of the above.
Correct Answer: A
Rationale: The correct answer is A because disturbed body image in an eating disorder patient involves a discrepancy between their perceived body image and reality. Monitoring weight, muscle, and fat congruence with height, frame, age, and sex helps assess if the patient's perception aligns with their actual physical state. Choice B focuses solely on calorie intake, which does not directly address body image perception. Choice C only considers weight, neglecting the importance of muscle and fat distribution in body image perception. Choice D is incorrect as option A is the most relevant outcome indicator for disturbed body image in this scenario.
In DSM-IV-TR intellectual disabilities are divided into a number of degrees of severity, depending primarily on the range of IQ score provided by the sufferer. One of these is Profound Mental Retardation, represented by an IQ score below:
- A. 20-25
- B. 25-30
- C. 15-20
- D. 15-Oct
Correct Answer: A
Rationale: Profound Mental Retardation: Defined by DSM-IV-TR as an IQ score below 20-25.
The elderly spouse of a 74-year-old male client states that she has noticed that her husband 'doesn't remember as well as he used to.' She explains that he has been putting on his coat before his shirt, and that he can never get their checkbook to balance as it did in the past. The client is exhibiting signs and symptoms typical of:
- A. Vascular dementia
- B. Alzheimer's disease
- C. Acute delirium
- D. Aging
Correct Answer: B
Rationale: The correct answer is B: Alzheimer's disease. The client's symptoms of memory loss, confusion, and difficulty with daily tasks point towards Alzheimer's disease, a progressive neurodegenerative disorder affecting memory and cognitive function. Vascular dementia (A) typically presents with a history of stroke or cardiovascular disease, which is not indicated in the scenario. Acute delirium (C) is a sudden and fluctuating change in mental status often caused by medical conditions or medications, not a progressive decline like Alzheimer's. Aging (D) is a natural process and does not explain the specific symptoms described.
An elderly patient brings a bag of medications to the clinic. The nurse finds bottles of medications as well as assorted pills in no containers in the bag. What is the nurse's priority action?
- A. Dispose of all medications that are not in properly labeled bottles.
- B. Confer with a family member about the patient's management of medication.
- C. Engage the patient in education about safe storage and labeling of medication.
- D. Ask the patient to name the purpose and date of expiration of each medication not in a bottle.
Correct Answer: C
Rationale: The correct answer is C because engaging the patient in education about safe storage and labeling of medication is the priority action. This approach promotes patient understanding and empowerment in managing their medications safely. It addresses the immediate concern of the medications being improperly stored and unlabeled. Option A focuses solely on disposal without addressing the root cause. Option B involves a third party and may not address the patient's immediate needs. Option D is important but not as urgent as ensuring safe storage and labeling. Ultimately, educating the patient promotes long-term safety and adherence to medication management.
Which statement by a patient with borderline personality disorder best indicates the treatment plan is helping?
- A. I think you are the best nurse on the unit.'
- B. I hate my doctor. He never gives me what I ask for.'
- C. I feel empty and want to cut myself, so I called you.'
- D. I'm never going to get high on drugs again.'
Correct Answer: C
Rationale: The correct answer is C. This statement indicates progress because the patient is demonstrating insight into their emotions, seeking help, and utilizing a coping strategy by reaching out for support instead of engaging in self-harm. Choice A does not provide information about progress in treatment. Choice B reflects a negative attitude towards the doctor. Choice D does not offer any insight into the patient's emotional state or progress in managing their behaviors.