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A patient diagnosed with schizophrenia reveals to the nurse that voices have warned of danger and adds, 'They're so loud they frighten me. Do you hear them?' The nurse's best initial response would be:
- A. I know these voices are very real to you, but I don't hear them.'
- B. Don't worry. You're safe in the hospital. I won't let anything happen to you.'
- C. Tell me more about the voices. Are they men or women? How many are there?'
- D. What do you do in order to keep yourself occupied so you don't hear the voices?'
Correct Answer: A
Rationale: The correct answer is A because it acknowledges the patient's experience without dismissing or invalidating it. By stating, "I know these voices are very real to you, but I don't hear them," the nurse validates the patient's reality and expresses empathy. This response helps build trust and rapport, which is crucial in establishing a therapeutic relationship.
Choice B is incorrect because it dismisses the patient's concerns and offers false reassurance, which may not be effective in addressing the patient's distress.
Choice C is incorrect as it focuses on gathering more information about the voices without addressing the patient's immediate emotional distress.
Choice D is incorrect because it shifts the focus away from the patient's current experience and onto distractions, which may not be helpful in addressing the patient's distressing symptoms.
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A patient with anorexia nervosa in outpatient treatment has begun refeeding. Between the first and second appointment, the patient gained 8 pounds. The nurse should:
- A. Praise the weight gain.
- B. Assess lung sounds and extremities.
- C. Suggest implementation of an exercise program.
- D. Establish a higher target for weight gain for the next week.
Correct Answer: B
Rationale: The correct answer is B because assessing lung sounds and extremities is crucial after significant weight gain in a patient with anorexia nervosa to monitor for potential complications like refeeding syndrome. Praise in choice A may reinforce unhealthy behaviors. Choice C suggesting an exercise program may be harmful. Choice D could lead to excessive weight gain.
A client with antisocial personality disorder yells, 'Shut up about that, or I'll punch you in the nose!' and shakes his fist at another client in a group meeting after the client speaks negatively of illicit drug use. The nurse quickly determines that the client is at risk to act violently against others as evidenced by his aggressive behavior, verbal threats, and a history of impulsivity. Which is the best approach for the nurse to use?
- A. Seclude the client to protect the other clients and staff.
- B. Put the client in restraints to protect the milieu.
- C. Explore alternate ways to handle frustrating topics in the group.
- D. Tell the client to leave the group until he can behave appropriately.
Correct Answer: C
Rationale: The correct answer is C: Explore alternate ways to handle frustrating topics in the group. This approach is best because it focuses on addressing the underlying issue causing the client's aggression rather than just isolating or restraining the client. By exploring alternate ways to handle frustrating topics, the nurse can help the client develop healthier coping mechanisms and communication skills. This approach promotes therapeutic engagement and supports the client's growth and development.
Secluding the client (choice A) may escalate the situation and reinforce the client's aggressive behavior. Putting the client in restraints (choice B) is a restrictive measure that should only be used as a last resort for imminent danger. Telling the client to leave the group (choice D) may not address the root cause of the aggression and could lead to avoidance of addressing the client's issues.
A client with undifferentiated schizophrenia is readmitted for an acute exacerbation of the disorder. The goal of hospitalization is symptom stabilization. The nurse has documented that, in addition to experiencing auditory hallucinations, the client seems uninterested in activities, has difficulty completing tasks, seems forgetful, and seems puzzled by information and directions given by staff. The nurse's plans for intervention will be effective if these behaviors are attributed to:
- A. Social isolation
- B. Deficient knowledge
- C. Situational low self-esteem
- D. Problems in cognitive functioning
Correct Answer: D
Rationale: The correct answer is D: Problems in cognitive functioning. In undifferentiated schizophrenia, cognitive deficits such as difficulty completing tasks, forgetfulness, and confusion are common symptoms. These behaviors are indicative of cognitive impairment rather than social isolation, deficient knowledge, or low self-esteem. Cognitive deficits in schizophrenia can affect memory, attention, and problem-solving abilities, leading to difficulties in daily functioning. Therefore, the nurse's interventions should focus on addressing these cognitive impairments to stabilize the client's symptoms.
While planning care for a preschool child who has been physically and sexually abused, the nurse includes play therapy because it assists the child to:
- A. Act out aggression in an acceptable manner
- B. Express feelings that cannot easily be verbalized
- C. Interact with other children in the appropriate age group
- D. Learn adaptive behaviors through acting
Correct Answer: B
Rationale: The correct answer is B: Express feelings that cannot easily be verbalized. Play therapy allows preschool children to express their emotions, trauma, and experiences through play activities, as they may not have the verbal skills to communicate their feelings effectively. This form of therapy helps the child process their emotions and experiences in a safe and non-threatening environment.
Incorrect Choices:
A: Acting out aggression in an acceptable manner is not the primary goal of play therapy for abused children. It is more about emotional expression and healing.
C: Interacting with other children in the appropriate age group is not the focus of play therapy for abused children. The primary goal is to address the trauma and emotional distress.
D: Learning adaptive behaviors through acting is not the main purpose of play therapy for abused children. It is more about emotional healing and expression.
Which is NOT a contributing factor to postpartum blues?
- A. Hormone shifts
- B. Lack of sleep
- C. Stress
- D. History of depression
Correct Answer: D
Rationale: History of depression (D) is a contributor to postpartum depression, not postpartum blues. Hormone shifts (A), lack of sleep (B), and stress (C) are common triggers for the transient sadness of postpartum blues.