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A patient who has been hospitalized for 2 days remains delusional and anxious and does not yet appear to be ready to give up the delusions. What intervention will best help the patient focus less on the delusion?
- A. Schedule time for the patient to read and listen to music.
- B. Plan activities that require physical skills and constructive use of time.
- C. Begin planning for discharge by engaging the patient in psychoeducation.
- D. Discuss personal goals related to improved socialization with the patient.
Correct Answer: B
Rationale: The correct answer is B because engaging in activities that require physical skills and constructive use of time can help the patient shift their focus away from the delusions. Physical activities can help reduce anxiety and provide a sense of accomplishment, which can help distract the patient from the delusions. It also promotes a sense of normalcy and routine, which can aid in grounding the patient in reality.
Choice A is incorrect because reading and listening to music may not actively engage the patient in a way that helps them shift their focus from the delusions. Choice C is incorrect because planning for discharge may be premature and may not address the immediate need to distract the patient from the delusions. Choice D is incorrect because discussing personal goals related to improved socialization may not be effective in helping the patient focus less on the delusions at this stage.
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When analyzing the behaviors of a 23-year-old who meets the criteria for antisocial personality disorder, the nurse recognizes that the following nursing diagnosis would be pertinent to his care:
- A. Risk for self-mutilation
- B. Disturbed personal identity
- C. Impaired social interaction
- D. Social isolation
Correct Answer: C
Rationale: Step-by-step rationale for choice C (Impaired social interaction) being the correct answer:
1. Antisocial personality disorder is characterized by a lack of regard for others and a pattern of violating their rights.
2. Individuals with this disorder often have difficulty forming and maintaining healthy relationships.
3. Impaired social interaction reflects the challenges the individual faces in relating to others.
4. This nursing diagnosis would address the core issue of social dysfunction in individuals with antisocial personality disorder.
Summary of why the other choices are incorrect:
A. Risk for self-mutilation - Not typically associated with antisocial personality disorder, more common in other mental health conditions.
B. Disturbed personal identity - Not a primary concern in antisocial personality disorder, which is more about behavior than identity.
D. Social isolation - While individuals with antisocial personality disorder may isolate themselves, impaired social interaction is a more direct and specific issue to address in their care.
In Anorexia Nervosa (AN), which of the following is a characteristic clinical feature?
- A. Intense fear of gaining weight
- B. Intense desire to binge eat
- C. Intense desire to vomit
- D. Intense desire to keep themselves busy
Correct Answer: A
Rationale: Per DSM-5, an intense fear of gaining weight is a hallmark of Anorexia Nervosa, distinguishing it from other eating disorders.
A 72-year-old widow has just returned home after 2 weeks in the hospital after a fall. She lives alone and is visited weekly by her son. She takes digoxin, hydrochlorothiazide, and an antihypertensive drug. She also has a prescription for diazepam (Valium) as needed for moderate to severe anxiety. When the visiting nurse stopped by 2 days after discharge, he found the woman confused and disoriented, with an unsteady gait. The patient asks him who he is and why he is there. The nurse correctly deduces that the most likely cause for the changes seen in the patient is:
- A. Delirium.
- B. Dementia.
- C. Drug toxicity.
- D. None of the above.
Correct Answer: A
Rationale: The correct answer is A: Delirium. The patient's sudden onset of confusion, disorientation, and unsteady gait after discharge from the hospital suggests delirium. Delirium is an acute change in mental status with fluctuating symptoms, often caused by underlying medical conditions, medications (such as diazepam), or environmental factors. In this case, the recent hospitalization, multiple medications, and potential stressors like living alone and recent fall increase the risk for delirium.
Incorrect choices:
B: Dementia is a chronic, progressive condition characterized by memory loss and cognitive decline. The sudden onset of symptoms in this case is not consistent with dementia.
C: Drug toxicity could be a possibility given the patient's medication list, but delirium is a more likely explanation due to the acute onset of symptoms post-hospitalization.
D: None of the above is incorrect because delirium is the most likely cause based on the patient's presentation and risk factors.
A nurse is caring for a patient with bulimia nervosa. What is the most important aspect of the treatment plan?
- A. To encourage purging behaviors to eliminate binge episodes.
- B. To provide a structured meal plan and monitor food intake.
- C. To focus solely on achieving weight loss.
- D. To offer therapy focused on body image without addressing eating behaviors.
Correct Answer: B
Rationale: The correct answer is B: To provide a structured meal plan and monitor food intake. This is crucial in the treatment of bulimia nervosa as it helps establish regular eating patterns, prevent binge episodes, and promote healthy nutrition. Providing structure and monitoring food intake also helps in addressing underlying psychological issues related to disordered eating. Encouraging purging behaviors (choice A) can worsen the condition and lead to serious health complications. Focusing solely on weight loss (choice C) may reinforce unhealthy behaviors and neglect the holistic approach needed for recovery. Offering therapy focused only on body image (choice D) overlooks the critical component of addressing eating behaviors and nutritional needs.
An adolescent patient is diagnosed with dementia. The patient's age would cause a nurse to suspect which underlying condition sometimes associated with this diagnosis?
- A. Head trauma
- B. Neurosyphilis
- C. Pick disease
- D. Hypothyroidism
Correct Answer: A
Rationale: The correct answer is A: Head trauma. Adolescents are less likely to develop dementia due to age-related neurodegenerative diseases. Head trauma can lead to cognitive impairment and memory loss, mimicking symptoms of dementia. Neurosyphilis is a sexually transmitted infection affecting the brain, not common in adolescents. Pick disease is a rare neurodegenerative disorder more commonly seen in older adults. Hypothyroidism can cause cognitive symptoms but is not typically associated with dementia in adolescents.