Nokea
A patient is currently in an abusive relationship with the father of her only child and tells a nurse that her partner 'is really sorry for hitting me and wants to come back and be part of the family again.' The nurse should provide which intervention?
- A. Share with the patient that abusers seldom voluntarily stop abusing.
- B. Identify groups that focus on treatment for individuals who are abusive.
- C. Tell the patient to continue the relationship, but focus on how to minimize the abuse.
- D. Tell the patient's partner that any continued abuse will be reported to the police.
Correct Answer: B
Rationale: The correct answer is B: Identify groups that focus on treatment for individuals who are abusive. This intervention is appropriate because it addresses the root cause of the abusive behavior, which is the partner's abusive tendencies. By connecting the abuser to groups that specialize in treating abusive behavior, there is a chance for change and rehabilitation.
A: Sharing with the patient that abusers seldom voluntarily stop abusing may not be helpful as it does not provide a proactive solution to address the abusive behavior.
C: Telling the patient to continue the relationship and focus on minimizing the abuse is dangerous as it normalizes and enables the abusive behavior, putting the patient at further risk.
D: Threatening the patient's partner with reporting to the police may escalate the situation and put the patient at higher risk of harm. It does not address the underlying issue of the partner's abusive behavior.
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A client with schizophrenia tells the nurse as they sit in the day room, 'I hear voices telling me bad things.' The most therapeutic response the nurse can make is:
- A. Tell me what the voices are saying.'
- B. I understand you hear these so-called voices, but I hear only the people in the room talking.'
- C. The voices are not real. They're only your imagination.'
- D. Do you think the voices would go away if we went into your room to talk?'
Correct Answer: B
Rationale: The correct answer is B because it demonstrates empathy and validation of the client's experience. By acknowledging the client's reality of hearing voices and emphasizing that the nurse does not hear them, the nurse establishes trust and rapport. This response shows active listening and validates the client's feelings without judgment.
Incorrect responses:
A: Asking the client to describe the voices may increase distress and is not as supportive as acknowledging their experience.
C: Dismissing the voices as not real can invalidate the client's experience and may lead to mistrust.
D: Suggesting a change of location does not address the client's immediate concerns and may not be therapeutic in this situation.
A patient with bipolar disorder, mania, relapsed after discontinuing lithium. The health care provider prescribes lithium 600 mg BID and olanzapine (Zyprexa) 10 mg BID. What is the rationale for addition of olanzapine to the lithium regime? It will:
- A. Minimize the side effects of lithium.
- B. Bring hyperactivity under rapid control.
- C. Potentiate the antimanic action of lithium.
- D. Be used for long-term control of hyperactivity.
Correct Answer: B
Rationale: The correct answer is B: Bring hyperactivity under rapid control.
Rationale:
1. Olanzapine is an atypical antipsychotic known for its rapid onset of action in controlling manic symptoms, including hyperactivity.
2. Lithium alone may take time to reach therapeutic levels and show efficacy, while olanzapine can provide more immediate relief.
3. Combining olanzapine with lithium can address acute manic symptoms effectively and quickly.
4. Choice A is incorrect because olanzapine does not specifically minimize lithium's side effects.
5. Choice C is incorrect as olanzapine does not directly potentiate lithium's antimanic action.
6. Choice D is incorrect because olanzapine is typically used for acute symptom management rather than long-term control.
In a sad voice, an elderly patient tells the nurse of the recent deaths of a spouse and close friend. The patient has no other family and only a few acquaintances in the community. The nurses priority is to determine whether which nursing diagnosis applies to this patient?
- A. Risk for suicide related to recent deaths of significant others
- B. Anxiety related to sudden and abrupt lifestyle changes
- C. Social isolation related to loss of existing family
- D. Spiritual distress related to anger with God
Correct Answer: A
Rationale: The patient appears to be experiencing normal grief related to the loss of her family, but because of age and social isolation, the risk for suicide should be determined and has high priority. No defining characteristics exist for the diagnoses of anxiety or spiritual distress. The patients social isolation is important, but the risk for suicide has higher priority.
A 10-year-old boy is diagnosed with gender dysphoria. Which assessment finding would the nurse expect?
- A. Having tea parties with dolls
- B. A compromised sexual response cycle
- C. Identifying with boys who are athletic
- D. Intense urges to watch his parents have sex
Correct Answer: A
Rationale: The correct answer is A because a child with gender dysphoria may display behaviors that align with the gender they identify with, such as engaging in activities typically associated with that gender. Tea parties with dolls may indicate the child's preference for activities stereotypically linked to girls, indicating a mismatch between their assigned gender and gender identity. Choices B, C, and D are incorrect as they do not align with typical assessment findings for gender dysphoria in children. B is more related to sexual dysfunction, C is a common behavior for all children, and D is inappropriate and unrelated to the diagnosis of gender dysphoria.
A patient has not come out of her room for breakfast. The nurse finds the patient moving restlessly about her room in a disorganized manner. The patient is talking to herself, and her verbal responses to the nurse are nonsensical and suggest disorientation. The nurse notices that the patient's skin is hot and dry, and her pupils are somewhat dilated. All these symptoms are significant departures from the patient's recent presentation. The patient is likely experiencing ______, and the nurse should ______.
- A. anticholinergic toxicity"¦check vital signs and prepare to use a cooling blanket stat
- B. relapse of her psychosis"¦administer PRN antipsychotic drugs and notify her physician
- C. neuroleptic malignant syndrome"¦contact her physician for a transfer to intensive care
- D. agranulocytosis"¦hold her antipsychotic and draw blood for a complete blood count
Correct Answer: A
Rationale: The correct answer is A: anticholinergic toxicity. The patient's symptoms align with this diagnosis due to the disorganized behavior, nonsensical speech, disorientation, hot and dry skin, dilated pupils, and recent presentation changes. Anticholinergic toxicity can cause confusion, delirium, hyperthermia, and dilated pupils. Checking vital signs and preparing to use a cooling blanket are appropriate actions to manage the symptoms.
Choice B (relapse of psychosis) is incorrect because the symptoms are not typical of a psychotic relapse. Choice C (neuroleptic malignant syndrome) is incorrect as the symptoms do not completely align with this syndrome, which typically includes muscle rigidity and autonomic dysfunction. Choice D (agranulocytosis) is incorrect because it presents with low white blood cell count and not the symptoms described in the scenario.