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A patient with Alzheimer's disease has been determined to have a dressing/grooming self-care deficit. Which intervention(s) would be appropriate for this nursing diagnosis? Select all that apply.
- A. Replace personal clothing with gym clothes that all match each other.
- B. Label the patient's clothing with his name and name of the item.
- C. Provide clothing with elastic waistbands and hook-and-loop closures.
- D. None of the above.
Correct Answer: A
Rationale: Rationale: Option A is correct because replacing personal clothing with matching gym clothes simplifies dressing, reducing confusion for a patient with Alzheimer's. This intervention promotes independence and minimizes frustration. Labeling clothing (Option B) may help in identifying items but does not address the deficit. Clothing with elastic waistbands and closures (Option C) may be helpful but does not directly address the deficit. "None of the above" (Option D) is incorrect as Option A is an appropriate intervention.
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A nurse is caring for a patient who has a maladaptive response to eating regulation. The patient tells the nurse, 'I know my parents are already upset, but I need to lose another 10 pounds to be at an ideal weight.' This statement suggests that the best treatment setting for this patient would be:
- A. the hospital.
- B. an outpatient program.
- C. a day treatment program.
- D. at home with weekly nursing visits.
Correct Answer: A
Rationale: The correct answer is A: the hospital. This patient's maladaptive eating behavior and desire to lose more weight despite concerns from family indicate a serious condition requiring intensive care and monitoring. In the hospital, the patient can receive immediate medical attention, nutritional support, and psychological intervention to address underlying issues. Outpatient programs (B) may not offer sufficient supervision, while day treatment programs (C) may not provide round-the-clock care. Home with weekly nursing visits (D) is not appropriate for a patient with such severe eating regulation issues.
A patient with the diagnosis of schizophrenia, disorganized type, approaches the nurse and says, "It's beat, it's eat. No room for doom." The nurse can correctly assess this verbalization as:
- A. Neologisms
- B. Clanging
- C. Ideas of reference.
- D. Associative looseness.
Correct Answer: B
Rationale: The correct answer is B: Clanging. Clanging refers to the association of words based on sound rather than meaning. In this case, the patient's verbalization "It's beat, it's eat. No room for doom" demonstrates a pattern of words that rhyme or have similar sounds but lack coherent meaning. This is characteristic of clanging seen in disorganized schizophrenia. Neologisms (A) are newly created words with unique meanings, which is not evident here. Ideas of reference (C) involve misinterpreting unrelated events as being personally significant, which is not demonstrated in the patient's statement. Associative looseness (D) is a thought disorder where ideas are loosely associated, but the patient's statement does not show this specific feature.
Asking the husband to leave is likely to increase the client's anxiety and alter test results. Testing in the more familiar, comfortable surroundings of the home will yield more reliable results.
- A. Asking the husband to leave is likely to increase the client's anxiety and alter test results because the presence of a loved one can provide comfort and support during a potentially stressful situation.
- B. Testing in the more familiar, comfortable surroundings of the home will yield more reliable results because the client is in a setting where they feel safe and secure, which can help reduce anxiety and promote accurate test outcomes.
- C. Both A and B.
- D. None of the above.
Correct Answer: C
Rationale: The correct answer is C because both statements A and B provide valid reasons supported by psychological principles. Statement A is correct as the presence of a loved one can indeed provide comfort and support, reducing anxiety and potentially improving test outcomes. Statement B is also accurate as testing in familiar surroundings can help the client feel safe and secure, leading to more reliable results. Therefore, combining these two factors - the presence of a loved one and testing in a comfortable environment - would likely yield the most reliable results by addressing both emotional and environmental factors impacting the client's anxiety levels during the test.
An elderly patient brings a bag of medications to the clinic. The nurse finds a bottle labeled Ativan and one labeled lorazepam, both of which are to be taken BID. There are also bottles labeled hydrochlorothiazide, Inderal, and rofecoxib, each to be taken once daily. Which conclusion is accurate?
- A. Rofecoxib should not be taken with Ativan.
- B. Lorazepam interferes with the action of Inderal.
- C. The patient should not self-administer medication.
- D. Lorazepam and Ativan are the same drug, so the dose is excessive.
Correct Answer: D
Rationale: Lorazepam and Ativan are generic and trade names for the same drug (D), creating an accidental misuse situation with an excessive dose. The patient needs medication education and help with proper labeling; there is no evidence they cannot self-administer (C). Options A and B are not factually supported.
Suicidal tendency is most commonly seen with
- A. Schizophrenia
- B. Obsessive Disorders
- C. Mania
- D. Depression
Correct Answer: D
Rationale: Depression is the most common mental disorder associated with suicidal tendencies due to persistent feelings of hopelessness and despair.