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A patient diagnosed with dementia associated with excessive alcohol use is shown a pencil, a nickel, and a safety pin and asked to repeat the names of each. Later when asked to identify the same three items the patient is unable to do so. The nurse assesses this as:
- A. apraxia.
- B. agnosia.
- C. concreteness.
- D. catastrophizing.
Correct Answer: B
Rationale: The correct answer is B: agnosia. Agnosia is the inability to recognize or identify objects despite intact sensory abilities. In this case, the patient's inability to identify the pencil, nickel, and safety pin suggests a deficit in object recognition, which aligns with agnosia.
A: Apraxia is the inability to perform purposeful movements despite intact motor function, not related to object recognition.
C: Concreteness refers to difficulty understanding abstract concepts, not object recognition.
D: Catastrophizing is an irrational belief that something is far worse than it actually is, not related to the patient's inability to identify objects.
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A nurse is caring for a patient with bulimia nervosa. Which intervention should the nurse prioritize?
- A. Assist the patient in identifying triggers for binge-purge cycles.
- B. Focus solely on achieving a normal weight.
- C. Provide daily exercise routines to increase physical fitness.
- D. Discourage discussions about food to avoid increasing anxiety.
Correct Answer: A
Rationale: The correct answer is A. Assisting the patient in identifying triggers for binge-purge cycles is crucial in the treatment of bulimia nervosa. By understanding the triggers, the patient can learn to recognize and manage them effectively, leading to a reduction in the frequency of binge-purge episodes. This intervention helps address the root cause of the disorder and promotes long-term recovery.
Choice B is incorrect because solely focusing on achieving a normal weight overlooks the complex psychological factors involved in bulimia nervosa. Choice C is incorrect as providing daily exercise routines may exacerbate the patient's obsession with weight and body image. Choice D is incorrect as discouraging discussions about food can hinder the patient's ability to address their relationship with food and emotions.
The nurse performs a functional assessment of a client upon admission to a home health service. The purpose of this assessment is to determine the client's:
- A. Level of consciousness
- B. Ability to perform activities of daily living
- C. Degree of reasoning, judgment, and thought processes
- D. Level of functioning memory
Correct Answer: B
Rationale: The correct answer is B: Ability to perform activities of daily living. A functional assessment in home health services focuses on evaluating the client's ability to independently perform daily tasks such as bathing, dressing, and preparing meals. This assessment helps determine the client's level of independence and need for assistance. Choices A, C, and D are incorrect because they do not directly assess the client's ability to perform activities of daily living, which is the primary purpose of a functional assessment in this context.
A patient with mania has not eaten or slept for 3 days. Which nursing diagnosis has priority?
- A. Risk for injury
- B. Ineffective coping
- C. Ineffective management of therapeutic regime
- D. Imbalanced nutrition
Correct Answer: D
Rationale: The correct answer is D: Imbalanced nutrition. Priority is given to physiological needs. The patient not eating for 3 days can lead to serious health complications. This nursing diagnosis addresses the immediate risk to the patient's physical well-being. Choices A, B, and C are important but addressing the patient's nutritional needs is the priority to prevent further deterioration in their condition.
A patient living independently had command hallucinations to shout warnings to neighbors. After a short hospitalization, the patient was prohibited from returning to the apartment. The landlord said, 'You cause too much trouble.' What problem is the patient experiencing?
- A. Grief
- B. Stigma
- C. Homelessness
- D. Nonadherence
Correct Answer: B
Rationale: The inability to obtain shelter because of negative attitudes about mental illness is an example of stigma. Stigma is defined as damage to reputation, shame, and ridicule society places on mental illness. Data are not present to identify grief as a patient problem. Data do not suggest that the patient is actually homeless.
What environmental conditions should the nurse arrange for a patient with delirium and altered perceptions of their environment?
- A. Provide a quiet, well-lit room without glare or shadows.
- B. Have the patient sit by the nurse's desk while awake.
- C. Reduce room lighting to minimize overstimulation.
- D. None of the above.
Correct Answer: A
Rationale: The correct answer is A because a quiet, well-lit room without glare or shadows helps reduce environmental stimuli that can exacerbate delirium and altered perceptions. This environment promotes calmness and clarity for the patient. Choice B is incorrect as it may increase distractions and stimuli. Choice C may lead to inadequate lighting that can worsen confusion. Choice D is incorrect as environmental modifications are crucial for managing delirium.