Nokea
A patient was admitted in a semistuporous catatonic state. Family states that the patient has neither left the apartment nor attended to personal hygiene for several weeks. The patient's last 48 hours have been spent lying in bed, mute and motionless. The nursing diagnosis that should be considered the priority is:
- A. self-care deficit.
- B. situational low self-esteem.
- C. disturbed thought processes.
- D. impaired verbal communication.
Correct Answer: A
Rationale: The correct answer is A: self-care deficit. The patient's symptoms indicate a lack of ability to perform self-care activities, which poses a risk to their health and well-being. This is a priority as addressing this issue will directly impact the patient's physical health and overall functioning. Situational low self-esteem (B) is not the priority as it focuses on the patient's emotional state rather than their immediate physical needs. Disturbed thought processes (C) and impaired verbal communication (D) may be present but are not the priority over the patient's inability to perform self-care activities.
You may also like to solve these questions
Which is a key nursing consideration when planning care for a patient with bulimia nervosa?
- A. Allow the patient to choose their preferred food options.
- B. Provide a structured environment with clear expectations around eating behaviors.
- C. Monitor for signs of weight gain and decrease calorie intake accordingly.
- D. Encourage the patient to participate in regular exercise routines.
Correct Answer: B
Rationale: The correct answer is B: Provide a structured environment with clear expectations around eating behaviors. This is important in managing bulimia nervosa as it helps establish a routine, promotes healthy eating habits, and prevents binge-purge cycles. It provides consistency and boundaries, reducing the likelihood of impulsive behaviors.
Incorrect choices:
A: Allowing the patient to choose their preferred food options can enable unhealthy eating patterns and reinforce disordered behaviors.
C: Monitoring for weight gain and decreasing calorie intake can worsen the patient's condition and perpetuate their obsession with weight and food.
D: Encouraging regular exercise routines may exacerbate the patient's unhealthy relationship with food and body image, leading to excessive exercising or compensatory behaviors.
Schizophrenia in children as young as 5 years:
- A. Is a myth
- B. Can occur
- C. Never occurs
- D. Cannot occur
Correct Answer: B
Rationale: The correct answer is B: Can occur. Schizophrenia can indeed manifest in children as young as 5 years old, although it is rare. Symptoms may include hallucinations, delusions, disorganized speech, and impaired social interactions. Early diagnosis and intervention are crucial for managing the condition. Choice A is incorrect as schizophrenia in young children is not a myth. Choice C is incorrect as schizophrenia can occur in children. Choice D is incorrect as there have been documented cases of schizophrenia in children as young as 5 years old.
Which symptom reported by a client, age 35, who was sexually abused as a child reflects the diagnosis of posttraumatic stress disorder (PTSD)?
- A. Reexperiencing the traumatic event
- B. Refusing to go to public places from which escape may be difficult
- C. Seeking advice and guidance prior to making any significant decision
- D. Ruminating over the abuse with friends and acquaintances
Correct Answer: A
Rationale: The correct answer is A: Reexperiencing the traumatic event. This symptom is a key criterion for diagnosing PTSD according to the DSM-5. It includes flashbacks, nightmares, or intrusive thoughts related to the traumatic event. This symptom indicates that the client is experiencing distressing memories of the past abuse, which is a common feature of PTSD.
Choice B is incorrect because it describes agoraphobia, a separate anxiety disorder, not specific to PTSD. Choice C is incorrect as seeking advice is not a diagnostic criterion for PTSD. Choice D is incorrect because ruminating over the abuse with others may reflect coping mechanisms or seeking support, but it does not necessarily indicate PTSD.
Which statement best describes postpartum blues?
- A. A rare condition that impacts bonding between mother and baby.
- B. A transient, self-limiting period of sadness after the birth of the baby.
- C. A psychiatric diagnosis similar to dysthymia.
- D. A transient period of sadness that usually moves into postpartum depression.
Correct Answer: B
Rationale: This definition of postpartum blues (B) differentiates it from dysthymia and postpartum depression. It occurs in 70 percent of new mothers, making it common, transient, and self-limiting.
The medication donepezil (Aricept) frequently is used to treat the early-stage symptoms of Alzheimer's disease. When administering this particular medication, the nurse should be especially alert to assess the client for:
- A. Weight changes
- B. Tremors
- C. Increased sweating
- D. Alterations in blood pressure
Correct Answer: D
Rationale: The correct answer is D: Alterations in blood pressure. Donepezil can cause changes in blood pressure as a side effect. Nurses should monitor for orthostatic hypotension and changes in blood pressure to prevent adverse effects. Weight changes (A), tremors (B), and increased sweating (C) are not commonly associated with donepezil and are less likely to be significant concerns when administering this medication for Alzheimer's disease.