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A patient with acute mania approaches the nurse, waves a newspaper, and says, "I want the phone right now. I need to call this store while their sale is going on. I need ten dresses and four pairs of shoes." Select the nurse's best intervention.
- A. Suggest the patient ask a friend do the shopping and bring purchases to the unit.
- B. Invite the patient to sit with the nurse and look at new fashion magazines.
- C. Tell the patient phone use is not allowed until self-control is improved.
- D. Ask whether the patient has enough money to pay for the purchases.
Correct Answer: C
Rationale: The correct answer is C because the patient's behavior is impulsive and reflects poor judgment, which are common symptoms of acute mania. By telling the patient that phone use is not allowed until self-control is improved, the nurse is setting a boundary to prevent further impulsive actions. This intervention prioritizes safety and helps maintain a therapeutic environment.
A: This option does not address the immediate need to manage the patient's impulsive behavior and may put the friend in a potentially risky situation.
B: Inviting the patient to look at fashion magazines does not address the impulsivity and may even reinforce the behavior.
D: Asking about the patient's financial situation is not the most appropriate intervention at this time.
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A nurse assesses four patients between the ages of 70 and 80. Which patient has the highest risk for alcohol abuse? The patient who:
- A. consumes 1 glass of wine nightly with dinner
- B. began drinking alcohol daily after retirement and says, 'A few drinks keep my mind off my arthritis.'
- C. drank socially throughout adult life and continues this pattern, saying 'Ive earned the right to do as I please.'
- D. abused alcohol between the ages of 25 and 40 but now abstains and occasionally attends Alcoholics Anonymous (AA)
Correct Answer: B
Rationale: Alcohol abuse and dependence can develop at any age, and the geriatric population is particularly at risk. Losses, such as retirement, widowhood, and loneliness, are often related. The distracters describe patients with a lower risk for alcohol abuse.
The nurse wants to enroll a patient with poor social skills in a training program for patients diagnosed with schizophrenia. Which description accurately describes social skills training?
- A. Patients learn to improve their attention and concentration
- B. Group leaders provide support without challenging patients to change
- C. Complex interpersonal skills are taught by breaking them into simpler behaviors
- D. Patients learn social skills by practicing them in a supported employment setting
Correct Answer: C
Rationale: In social skills training, complex interpersonal skills are taught by breaking them down into component behaviors that are covered in a stepwise fashion. Social skills training is not based in employment settings, although such skills can be addressed as part of supported employment services. The other distracters are less relevant to social skills training.
A patient is admitted with a tentative diagnosis of delirium. The patient repeatedly mistakes one of the nursing staff for a family member. The nurse documents that this patient is experiencing a disturbance in which area of functioning?
- A. Consciousness
- B. Attention
- C. Perception
- D. Cognition
Correct Answer: C
Rationale: The correct answer is C: Perception. In this scenario, the patient's repeated mistake of identifying a nursing staff as a family member indicates a disturbance in perception, specifically in the recognition and interpretation of sensory information. This confusion is not related to consciousness (A), as the patient is awake and aware. It is also not solely an issue of attention (B), as attention involves the ability to focus on specific stimuli rather than the interpretation of those stimuli. While cognition (D) encompasses various mental processes, such as memory and problem-solving, the primary issue in this case is the misinterpretation of sensory input, aligning with the disturbance in perception.
A patient with schizophrenia who admits to auditory hallucinations anxiously tells the nurse, 'The voice is telling me to do things.' Which of the following responses should the nurse make next?
- A. Do you recognize the voice you hear?'
- B. How long has this been happening?'
- C. Does what the voice tells you to do frighten you?'
- D. What is the voice telling you to do?'
Correct Answer: D
Rationale: The correct answer is D: "What is the voice telling you to do?" This response helps the nurse assess the content and potential danger of the hallucinations, guiding further interventions. Option A focuses on recognition, which is less urgent. Option B addresses duration, not immediate safety. Option C inquires about fear but does not directly address the hallucination's content. By asking what the voice commands, the nurse gains crucial insight for risk assessment and safety planning.
When the family of a client who has been diagnosed with a dementia secondary to normal pressure hydrocephalus asks the nurse about prognosis, the nurse should reply:
- A. Unfortunately the prognosis is for a downhill course ending in death.'
- B. There will be good days and bad days for the rest of the client's life.'
- C. The symptoms usually remit after a shunt is inserted to drain fluid.'
- D. We'll try our very best, but only time will tell how successful we are.'
Correct Answer: C
Rationale: The correct answer is C because normal pressure hydrocephalus (NPH) symptoms typically improve after a shunt is inserted to drain the excess cerebrospinal fluid, leading to a better prognosis. This intervention can help alleviate symptoms such as gait disturbances, cognitive impairment, and urinary incontinence associated with NPH.
Choice A is incorrect as it inaccurately states that the prognosis is inevitably poor, which is not true for NPH with appropriate treatment. Choice B is incorrect because NPH symptoms can be effectively managed with treatment, so it is not accurate to say that there will always be good and bad days for the rest of the client's life. Choice D is incorrect as it does not provide specific information about the positive impact of shunt insertion on NPH symptoms and prognosis.