Nokea
A patient tries to gouge out their eye in response to auditory hallucinations. The nurse would analyze this behavior as indicating:
- A. Derealization
- B. Inappropriate affect
- C. Impaired impulse control
- D. Inability to manage anger
Correct Answer: C
Rationale: Self-harm in response to hallucinations reflects impaired ability to control impulses and respond safely to internal stimuli.
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An elderly patient brings a bag of medications to the clinic. The nurse finds a bottle labeled Ativan and one labeled lorazepam, both of which are to be taken BID. There are also bottles labeled hydrochlorothiazide, Inderal, and rofecoxib, each to be taken once daily. Which conclusion is accurate?
- A. Rofecoxib should not be taken with Ativan
- B. Lorazepam and Ativan are the same drug, so the dose is excessive.
- C. Lorazepam interferes with the action of Inderal.
- D. The patient should not self-administer medication.
Correct Answer: B
Rationale: Ativan and lorazepam are the same drug, so the patient is taking an excessive dose of lorazepam. This requires intervention by the nurse to prevent harm.
What would be an appropriate short-term outcome for a patient diagnosed with residual schizophrenia who exhibits ambivalence?
- A. Decide their own daily schedule.
- B. Decide which unit groups they will attend.
- C. Choose between two outfits to wear each morning.
- D. Choose which clinic staff member to work with.
Correct Answer: C
Rationale: Residual schizophrenia can cause ambivalence or difficulty making decisions. Offering simple choices reduces decision-making stress and promotes autonomy.
The patient and the nurse have agreed on problems to be addressed during a short course of outpatient therapy. At the beginning of the appointment, the patient states, “I’d like to work on the issue of relationships today.” Which assessment can be made?
- A. The nurse should suggest several alternative behaviors.
- B. The patient must be able to manage emotions before continuing.
- C. The relationship is moving from orientation to working phase.
Correct Answer: C
Rationale: The correct assessment to be made in this scenario is that the relationship is moving from the orientation phase to the working phase. In the orientation phase of the nurse-patient therapeutic relationship, the focus is on building rapport, establishing trust, and determining the patient's needs and goals. As the patient voluntarily expresses a desire to work on the issue of relationships, it indicates a transition to the working phase where the patient actively identifies problems to address and goals to achieve. This shift demonstrates progress in the therapeutic relationship as the patient is engaging in the therapeutic process and contributing to the agenda set for the appointment. It signifies a readiness for collaborative problem solving and intervention planning, emphasizing the importance of the patient's involvement in decision-making and goal-setting in the therapeutic process.
A patient is being seen for symptoms of insomnia and significant weight loss that has occurred during the 2 months since her husband’s death. What is the purpose of the query, “Describe how it has been for you since your husband died?”
- A. To display an attitude of concern and sympathy to the patient
- B. To learn whether the patient has a significant support system
- C. To rule out factors that may interfere with diagnosing her illness
- D. To determine the risk for pathologic grief and the need for grief therapy
Correct Answer: D
Rationale: The purpose of the query "Describe how it has been for you since your husband died?" is to determine the risk for pathologic grief and the need for grief therapy. The patient is experiencing symptoms of insomnia and significant weight loss following her husband's death, which could indicate complicated or pathologic grief. By asking this open-ended question, the healthcare provider can gain insight into the patient's emotional well-being, coping mechanisms, and overall adjustment to the loss. The response can help assess whether the patient might benefit from additional support or interventions, such as grief therapy, to help her navigate through the grieving process in a healthy manner. It is essential to identify and address any potential complications related to grieving to provide appropriate care and support to the patient.
During a grief-processing group, an elderly patient stated, For the first time since my husband died, Im having more good days than bad. This statement suggests that the patient has:
- A. Replaced old memories with new ones
- B. Reached the phase of reestablishment
- C. Completed her grief work successfully
- D. Determined she is ready to terminate the support group
Correct Answer: B
Rationale: Reestablishment is a phase of grief characterized by finding balance, experiencing positive moments, and reduced intensity of sadness.