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A patient who is admitted to the psychiatric unit with a diagnosis of obsessive-compulsive disorder spends a significant amount of time during the day and night washing their hands. On the third hospital day, the patient reports feeling better and more comfortable with the staff and other patients. The psychiatric-mental health nurse knows that the most appropriate nursing intervention is to:
- A. acknowledge the ritualistic behavior each time and point out that it is inappropriate
- B. allow the patient to carry out the ritualistic behavior, since it is helping them
- C. collaborate with the patient to reduce the amount of time they engage in ritualistic behavior
- D. ignore the ritualistic behaviors, and the behaviors will be eliminated due to lack of reinforcement
Correct Answer: C
Rationale: Collaborating to reduce rituals builds on the patient's progress, promoting control without enabling the behavior.
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What is the main issue for adolescents with anorexia?
- A. Anxiety.
- B. Control.
- C. Body image.
- D. Appropriate behavior.
Correct Answer: B
Rationale: The correct answer is B: Control. Adolescents with anorexia often have a strong desire for control over their lives, including their body and food intake. This need for control can manifest in restrictive eating behaviors. Anxiety (choice A) may be a symptom but is not the main issue. Body image (choice C) is a contributing factor, but not the primary issue. Appropriate behavior (choice D) is too broad and not specific to the core issue of control seen in anorexia.
Which beliefs by a nurse facilitate provision of safe, effective care for older adult patients? Select one tha does not apply.
- A. Sexual interest declines with aging.
- B. Older adults are able to learn new tasks.
- C. Aging results in a decline in restorative sleep.
- D. Older adults are prone to become crime victims.
Correct Answer: A
Rationale: Older adults can learn new tasks (B), experience a decline in restorative sleep (C), and are prone to crime (D), aiding effective care. Sexual interest doesn't universally decline (A), and isolation isn't typical (E); these are myths.
A newly admitted patient diagnosed with paranoid schizophrenia is hypervigilant and constantly scans the environment. He states that he saw two doctors talking in the hall and knows they were plotting to kill him. When charting, how should the nurse identify this behavior?
- A. Idea of reference
- B. Delusion of infidelity
- C. Auditory hallucination
- D. Echolalia
Correct Answer: A
Rationale: The correct identification for the behavior described is "A: Idea of reference." This term refers to the belief that neutral events are directed at oneself. In this case, the patient's belief that the doctors were plotting to kill him is an example of a false idea of reference. Delusion of infidelity (choice B) involves false beliefs about a partner's unfaithfulness, not relevant here. Auditory hallucination (choice C) pertains to false perceptions of hearing sounds, not applicable. Echolalia (choice D) is the repetition of words spoken by others, not seen in this scenario. Identifying the behavior as an idea of reference helps the nurse understand the patient's distorted perception of reality.
A patient with antisocial personality disorder tells Nurse A, 'You're a much better nurse than Nurse B said you were.' The patient tells Nurse B, 'Nurse A's upset with you for some reason.' To Nurse C the patient states, 'You'd like to think you're perfect, but I've seen three of your mistakes this morning.' These comments can best be assessed as:
- A. seductive.
- B. detached.
- C. guilt producing.
- D. manipulative.
Correct Answer: D
Rationale: The correct answer is D: manipulative. The patient is using different strategies to manipulate each nurse's emotions and behavior for personal gain. In the first scenario, the patient is attempting to create a divide between Nurse A and Nurse B by praising Nurse A and implying Nurse B's incompetence. In the second scenario, the patient is trying to instigate conflict between Nurse A and Nurse B by falsely suggesting Nurse A's negative feelings towards Nurse B. In the third scenario, the patient is employing a manipulative tactic by undermining Nurse C's confidence and competence. These behaviors demonstrate a pattern of manipulation aimed at controlling and influencing the nurses' perceptions and actions. Choices A, B, and C do not accurately capture the manipulative intent behind the patient's actions.
The caregiver for a client with moderate to severe dementia tells the nurse, 'I'm exhausted. He wanders at night instead of sleeping, so I get no rest. I'm afraid to leave him during the day, so I have to take him to the grocery store and to the laundromat. When I'm busy there, he often wanders off. Still, I have to do it all.' The nurse recognizes the need to provide teaching for this caregiver. An appropriate outcome is that the caregiver will:
- A. Feel justified in putting the client in a nursing home
- B. Verbalize realistic self-expectations
- C. Cease abusive interactions with the client
- D. Feel comfortable leaving the client alone one morning a week
Correct Answer: B
Rationale: The correct answer is B: Verbalize realistic self-expectations. This is the most appropriate outcome to address the caregiver's situation. By verbalizing realistic self-expectations, the caregiver can understand the importance of self-care and setting boundaries. This outcome promotes the caregiver's well-being while still providing care for the client.
Choice A is incorrect because putting the client in a nursing home may not be the best solution without exploring other options first. Choice C is incorrect as there is no mention of abusive interactions in the scenario. Choice D is incorrect because feeling comfortable leaving the client alone without addressing the caregiver's exhaustion and concerns may not be the most appropriate approach.