Nokea
A patient tells the nurse, 'I can't go to any unit meetings because when I get in that room, everyone can hear my thoughts.' The nurse can correctly assess this symptom as:
- A. concrete thinking.
- B. loose associations.
- C. thought broadcasting.
- D. auditory hallucinations.
Correct Answer: C
Rationale: The correct answer is C: thought broadcasting. This is when a person believes that others can hear their thoughts. In this scenario, the patient's belief that everyone in the unit meetings can hear their thoughts aligns with the symptom of thought broadcasting. It is a common manifestation of certain psychiatric disorders like schizophrenia.
Choice A, concrete thinking, refers to literal thinking without abstract reasoning and is not applicable in this context. Choice B, loose associations, involves disorganized and illogical thought patterns, which are not evident in the patient's statement. Choice D, auditory hallucinations, refers to hearing voices when no external stimulus is present, which is different from the patient's belief that others can hear their thoughts.
You may also like to solve these questions
A 14-year-old client on the eating disorders unit refuses to eat her meals and says to the nurse on the unit, 'You can't make me eat! There is nothing wrong with me.' The nurse will assess this as use of which defense mechanism?
- A. Repression.
- B. Rationalization.
- C. Sublimation.
- D. Denial.
Correct Answer: D
Rationale: The correct answer is D: Denial. Denial is a defense mechanism where an individual refuses to acknowledge reality to avoid discomfort. In this scenario, the client is denying the seriousness of their situation by refusing to eat and claiming there is nothing wrong. Repression (A) involves unconsciously blocking out unpleasant thoughts or feelings. Rationalization (B) is creating logical explanations to justify behavior. Sublimation (C) is redirecting negative impulses into positive behaviors. In this case, denial is the most fitting defense mechanism as the client is refusing to accept the reality of their eating disorder.
Which finding for a patient with an eating disorder most clearly indicates the need for hospitalization?
- A. Weight 15% below ideal weight
- B. Urine output less than 30 mL/hr
- C. Serum potassium 3.4 mEq/L
- D. Pulse rate 54 beats/min
Correct Answer: B
Rationale: The correct answer is B because urine output less than 30 mL/hr indicates severe dehydration and compromised kidney function, which can lead to organ failure. Hospitalization is necessary for immediate fluid resuscitation and monitoring. Option A is indicative of malnutrition but does not directly signify acute medical complications. Option C suggests hypokalemia, which can be managed on an outpatient basis. Option D, a low pulse rate, may be a sign of bradycardia but typically does not require immediate hospitalization unless accompanied by other severe symptoms.
An adult experienced a myocardial infarction six months ago. At a follow-up visit, this adult says, 'I haven't had much interest in sex since my heart attack. I finished my rehabilitation program, but having sex strains my heart. I don't know if my heart is strong enough.' Which nursing diagnosis applies?
- A. Deficient knowledge related to faulty perception of health status
- B. Disturbed self-concept related to required lifestyle changes
- C. Disturbed body image related to treatment side effects
- D. Sexual dysfunction related to self-esteem disturbance
Correct Answer: A
Rationale: The correct answer is A: Deficient knowledge related to faulty perception of health status. The patient's statement indicates a lack of understanding about their health status and the impact of their myocardial infarction on their sexual activity. The patient is attributing their decreased interest in sex to a fear of straining their heart, indicating a faulty perception of their health status. This nursing diagnosis addresses the patient's need for education and clarification about their condition to alleviate their concerns and improve their confidence in engaging in sexual activity safely.
Choices B, C, and D are incorrect because they do not directly address the patient's lack of knowledge and faulty perception about their health status. Disturbed self-concept (B) relates more to how the patient perceives themselves due to lifestyle changes, while disturbed body image (C) pertains to physical appearance changes. Sexual dysfunction (D) is related to difficulties in sexual function, which is not the primary issue in this scenario.
A client with anorexia nervosa has refused meal trays and supplemental feedings for 3 days following admission to the general hospital. The nurse can anticipate that intervention will include:
- A. IV infusions beginning immediately and continuing for 48 hours after client begins eating.
- B. Tube feedings until the client eats 90% of all meals for 1 day.
- C. Placing the client on suicide precautions and one-to-one observation.
- D. Limiting peer group visitors for 2 weeks.
Correct Answer: B
Rationale: The correct answer is B. Tube feedings until the client eats 90% of all meals for 1 day. This intervention is appropriate for a client with anorexia nervosa who is refusing to eat. Tube feedings ensure adequate nutrition while also encouraging the client to resume eating orally. It is a gradual approach that aims to transition the client back to regular eating habits.
Explanation for why other choices are incorrect:
A: IV infusions are not the first-line intervention for a client with anorexia nervosa refusing to eat. This choice does not address the underlying issue of the client's refusal to eat.
C: Placing the client on suicide precautions and one-to-one observation is not indicated solely based on refusal to eat. This choice does not address the nutritional needs of the client.
D: Limiting peer group visitors for 2 weeks does not address the client's refusal to eat and is not a relevant intervention in this situation.
A 34-year-old male admitted with catatonic schizophrenia has been mute and motionless for several days while at home prior to admission. He still appears stuporous in the hospital. Which nursing intervention would be an initial priority?
- A. Orienting the client to the unit
- B. Assessing the client for physical problems
- C. Establishing a nonthreatening relationship
- D. Reinforcing reality with the client
Correct Answer: B
Rationale: The correct answer is B: Assessing the client for physical problems. This is the initial priority because the client's muteness and motionless state could be due to an underlying physical issue that needs immediate attention, such as dehydration, malnutrition, or infection. By assessing for physical problems first, the nurse can rule out any urgent medical concerns before addressing the client's mental health needs.
A: Orienting the client to the unit - While important, this can be done after addressing any physical problems.
C: Establishing a nonthreatening relationship - Also essential, but assessing physical health takes precedence.
D: Reinforcing reality with the client - Not the immediate priority; physical assessment should come first.