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A patient who has been physically abused says, 'When I called the police, I just wanted my spouse to stop shoving me around and kicking me. I didn't want anyone to get in trouble. It's easy to get angry with me because I spend too much money.' Which nursing intervention would be most therapeutic for this patient?
- A. You feel your spouse was justified in the abuse because you overspent?'
- B. Tell your spouse that if this happens again, I'll report it to the police.'
- C. Your spouse abuses you when you overspend. So you think it will stop if you stop spending money?'
- D. I can understand that you don't want to press charges, but your spouse needs help controlling anger.'
Correct Answer: A
Rationale: The correct answer is A because it focuses on therapeutic communication by reflecting the patient's feelings and thoughts back to them without judgment. By repeating the patient's words, the nurse shows empathy and understanding, which can help build trust and rapport. Choices B and D may escalate the situation and go against the patient's wishes, potentially causing further harm. Choice C assumes a causal relationship between overspending and abuse, which is not appropriate and may blame the victim. Overall, choice A promotes a non-judgmental and supportive environment, which is crucial in addressing issues of abuse.
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An expected outcome for a client who hears voices telling him he is evil would be that by discharge, client will:
- A. Verbalize the reason the voices say he is evil
- B. Respond verbally to the voices
- C. Identify events that increase anxiety and promote hallucinations
- D. Integrate the voices into his personality structure in a positive manner
Correct Answer: C
Rationale: The correct answer is C because it focuses on addressing the underlying causes of the client's experience of hearing voices and feeling evil. By identifying events that increase anxiety and promote hallucinations, the client can work on reducing these triggers and managing his symptoms effectively. This approach is key for long-term improvement and recovery.
A: Verbalizing the reason the voices say he is evil does not address the root cause of the hallucinations and may not lead to effective coping strategies.
B: Responding verbally to the voices may not be therapeutic and could potentially reinforce the hallucinations.
D: Integrating the voices into his personality structure in a positive manner is not a recommended approach as it could lead to further distress and potentially harmful behaviors.
A patient with schizophrenia tells the nurse, 'Everyone must listen to me. I am the redeemer. I will bring peace to the world.' From this the nurse can determine that an appropriate nursing diagnosis is:
- A. Disturbed sensory perception: auditory.
- B. Risk for other-directed violence.
- C. Chronic low self-esteem.
- D. Nonadherence: medication.
Correct Answer: C
Rationale: Step 1: The patient's statement indicates grandiosity and delusions of grandeur, common in schizophrenia.
Step 2: Chronic low self-esteem is a common nursing diagnosis for those with grandiose delusions.
Step 3: The patient's belief of being the redeemer suggests underlying feelings of inadequacy.
Step 4: Addressing self-esteem can help the patient cope with such delusions.
Summary: A is incorrect as there is no mention of auditory hallucinations. B is incorrect as there is no immediate threat of violence. D is incorrect as nonadherence to medication is not evident in the scenario.
One bed is available on the eating disorders unit. Which patient should be admitted? The patient whose assessment findings show the weight dropped from:
- A. 150 to 102 pounds over a 4-month period.
- B. 120 to 90 pounds over a 3-month period.
- C. 130 to 100 pounds over a 2-month period.
- D. None of the above.
Correct Answer: A
Rationale: The correct answer is A because the patient has experienced a significant weight drop from 150 to 102 pounds over a 4-month period. This represents a loss of 48 pounds over a relatively longer period, indicating a more severe and prolonged issue with weight loss. The other choices show weight drops of 30 pounds over 3 months (B) and 30 pounds over 2 months (C), which are also concerning but not as severe or long-lasting as the situation described in choice A. Choice D is incorrect as at least one patient should be admitted based on the information provided.
A respected school coach was arrested after a student reported the coach attempted to have sexual contact. Which nursing action has priority in the period immediately following the coach's arrest?
- A. Determine the nature and extent of the coach's sexual disorder.
- B. Assess the coach's potential for suicide or other self-harm.
- C. Assess the coach's self-perception of problem and needs.
- D. Determine whether other children were harmed.
Correct Answer: B
Rationale: The correct answer is B: Assess the coach's potential for suicide or other self-harm. This is the priority nursing action because the coach may be experiencing intense emotional distress and may be at risk for harming themselves. By assessing for suicidal ideation or self-harm, the nurse can ensure the coach's safety and provide appropriate interventions if needed.
Choice A is incorrect because determining the nature and extent of the coach's sexual disorder is not the priority at this moment. Choice C is also incorrect as assessing the coach's self-perception of the problem and needs can be addressed after ensuring their immediate safety. Choice D is incorrect as determining whether other children were harmed is important but not the priority immediately following the coach's arrest.
A psychiatric technician asks the nurse to explain the difference between schizotypal personality disorder and schizophrenia. The information that should serve as the basis for the nurse's response is the fact that with schizotypal personality disorder:
- A. There is greater personality disorganization than in schizophrenia
- B. There may be misinterpretation of events but not psychosis
- C. The client will be sicker and require longer hospitalization
- D. The client will be more outgoing, actively seeking interactions with others
Correct Answer: B
Rationale: The correct answer is B: There may be misinterpretation of events but not psychosis. In schizotypal personality disorder, individuals may have odd beliefs, behaviors, and experiences, leading to misinterpretation of events, but they do not typically experience full-blown psychosis as seen in schizophrenia. This is a key distinction between the two disorders. Choice A is incorrect because schizophrenia is characterized by more severe disorganization of thoughts and behaviors. Choice C is incorrect as individuals with schizotypal personality disorder typically do not require long hospitalizations compared to those with schizophrenia. Choice D is incorrect as individuals with schizotypal personality disorder tend to be more socially isolated and have difficulty forming close relationships.