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A patient diagnosed with schizophrenia tells the community mental health nurse, 'I threw away my pills because they interfere with God's voice.' The nurse identifies what as the likely cause of the patient's ineffective management of the medication regimen?
- A. Inadequate discharge planning
- B. Poor therapeutic alliance with clinicians
- C. Impaired reasoning secondary to schizophrenia
- D. Dislike of the side effects of antipsychotic medications
Correct Answer: C
Rationale: The patient's ineffective management of the medication regimen is most closely related to impaired reasoning abilities. The patient believes in being an exalted person who hears God's voice, rather than an individual with a serious mental illness who needs medication to control symptoms. Data do not suggest that any of the other factors often relate to medication nonadherence.
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A patient diagnosed with severe and persistent mental illness who recently moved to a homeless shelter says, 'My life is out of control. I'm like a leaf at the mercy of the wind.' The nurse formulates the diagnosis Powerlessness. Outcomes will focus on which goal?
- A. Instilling hope
- B. Controlling anxiety
- C. Planning social activities
- D. Developing personal autonomy
Correct Answer: D
Rationale: Powerlessness is associated with feeling unable to control events in one's life. It is often associated with low self-esteem. The goal is to increase one's sense of autonomy. The scenario does not indicate hopelessness or anxiety. Socialization is not the primary need.
An adult has been feeling significant tension since losing a home through foreclosure. This person goes to park, feeds the birds, and then impulsively exposes himself to a group of parents and children. Which term applies to this behavior?
- A. Voyeurism
- B. Frotteurism
- C. Exhibitionism
- D. Sexual masochism
Correct Answer: C
Rationale: Exhibitionism is obtaining sexual pleasure from exposing one's genitalia to unsuspecting strangers. Voyeurism refers to obtaining sexual pleasure from observing people who are naked. Frotteurism is associated with obtaining sexual arousal by rubbing one's genitals against an unsuspecting person. Sexual masochism refers to deriving sexual pleasure from being humiliated, beaten, or otherwise made to suffer.
A patient diagnosed with severe and persistent mental illness lives in a homeless shelter. The priority nursing diagnosis for this patient is Powerlessness. Which intervention should be included in the plan of care?
- A. Encourage mutual goal setting.
- B. Verbally communicate empathy.
- C. Reinforce participation in activities.
- D. Demonstrate an accepting attitude.
Correct Answer: A
Rationale: Mutual goal setting is an intervention designed to promote feelings of personal autonomy and dispel feelings of powerlessness. Although it might be easier and faster for the nurse to establish a plan and outcomes, this action contributes to the patient's sense of powerlessness. Involving the patient in decision making empowers the patient and reduces feelings of powerlessness.
A person diagnosed with severe and persistent mental illness enters a shelter for the homeless. Which intervention should be the nurse's initial priority?
- A. Develop a relationship.
- B. Find supported employment.
- C. Administer prescribed medication.
- D. Teach appropriate health care practices.
Correct Answer: A
Rationale: Basic psychosocial needs do not change because a person is homeless. The nurse's initial priority should be establishing rapport. Once a trusting relationship is established, then the nurse can pursue other interventions.
A man tells the nurse, 'All my life, I have felt and acted like a woman while living in a man's body. For the past year, I have lived and dressed as a woman. I changed jobs to protect my new identity.' Which request is the patient likely to make to the health care provider?
- A. Can you refer me for psychological testing?'
- B. Will you prescribe hormonal therapy?'
- C. Will you alter my medical records?'
- D. What should I tell my parents?'
Correct Answer: B
Rationale: Before sexual reassignment surgery, the step that follows living as a member of the other sex is hormone therapy. The patient's decision to live as a woman makes this a natural request. Psychological testing occurs before sexual reassignment surgery, often after hormone therapy has begun. The patient has likely told his parents by this point.