Nokea
A patient with catatonic schizophrenia exhibits little spontaneous movement and demonstrates waxy flexibility. Which nursing intervention should receive the highest priority?
- A. Conducting passive range-of-motion exercises
- B. Exposing the patient to auditory and visual stimuli
- C. Interacting with the patient as if he is responding
- D. Including the patient in a variety of milieu activities
Correct Answer: A
Rationale: The correct answer is A: Conducting passive range-of-motion exercises. This intervention is the highest priority because it addresses the physical needs of the patient by preventing complications such as muscle stiffness and contractures due to prolonged immobility. Passive range-of-motion exercises also promote circulation and prevent pressure ulcers. Choice B is incorrect because excessive stimuli can overwhelm the patient. Choice C is incorrect as it assumes the patient is responding when they may not be. Choice D is incorrect as the patient may not be ready or able to participate in activities due to their catatonic state.
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Which of these nursing interventions would be most effective when using an empowerment model of intervention with an individual who has been abused?
- A. You have left your spouse many times only to return. Please tell me how you view this last time as being different from all the times you left before.'
- B. Last time we talked, you thought your children would miss their father, but you now think they seem happier and almost relieved by your separation.'
- C. So you're having doubts and want to return to your husband even though you know that he broke your arm and caused your miscarriage?'
- D. I support you returning to your spouse until you finally decide that 'enough is enough.''
Correct Answer: B
Rationale: The correct answer is B because it acknowledges the individual's evolving perspective and empowers them to recognize positive changes post-separation. This approach helps the individual build confidence in their decision-making process and fosters self-awareness.
Choice A focuses on past actions without addressing the current situation, Choice C uses a confrontational tone that may cause the individual to feel judged or defensive, and Choice D suggests a passive acceptance of returning to an abusive situation without promoting autonomy or self-efficacy.
During a treatment team meeting, the point is made that a client with schizophrenia has recovered from the acute psychosis but continues to demonstrate apathy, avolition, and blunted affect. The nurse who relates these symptoms to serotonin (SHT2) excess will suggest that the client receive:
- A. Haloperidol (Haldol)
- B. Chlorpromazine (Thorazine)
- C. Olanzapine (Zyprexa)
- D. Phenelzine (NardiI)
Correct Answer: C
Rationale: Rationale: Olanzapine (Zyprexa) is an atypical antipsychotic that targets multiple neurotransmitter systems, including serotonin. Serotonin excess is associated with symptoms like apathy, avolition, and blunted affect. Olanzapine, by blocking serotonin receptors, can help alleviate these symptoms in schizophrenia.
Summary of Incorrect Choices:
A: Haloperidol and B: Chlorpromazine are typical antipsychotics that primarily target dopamine receptors, not serotonin. They are more effective for positive symptoms of schizophrenia, not apathy and avolition.
D: Phenelzine is a monoamine oxidase inhibitor (MAOI) used for depression and anxiety disorders, not for schizophrenia symptoms related to serotonin excess.
The characteristic in individuals with personality disorders that makes it most necessary for staff to schedule frequent meetings is:
- A. flexibility and unconventional responses to stress.
- B. a desire to achieve emotional intimacy with staff.
- C. a tendency to evoke countertransference and conflict.
- D. an impaired ability to develop trusting relationships.
Correct Answer: C
Rationale: The correct answer is C because individuals with personality disorders often evoke countertransference and conflict in staff due to their challenging behaviors and interpersonal dynamics. This can lead to potential misunderstandings and ineffective treatment if not addressed through frequent meetings. Option A is incorrect as flexibility and unconventional responses to stress are not typically the primary concern necessitating frequent meetings. Option B is incorrect as a desire for emotional intimacy is not necessarily a reason for staff to schedule frequent meetings. Option D is incorrect as an impaired ability to develop trusting relationships might be a symptom of a personality disorder, but it is not the characteristic that most necessitates frequent meetings.
You are a nurse meeting for the first time with a stage 3 Alzheimer's patient who is newly referred to your home health agency. Which assessment data about the patient and caregiver(s) would be most important to acquire during your first visit to the family's home?
- A. Is the house design such that patient access to exits and stairways can be restricted?
- B. Does the family understand that the disease is likely to prove fatal within 3 to 5 years?
- C. What resources is the patient's family able to access in their particular community?
- D. None of the above.
Correct Answer: A
Rationale: Step-by-step rationale:
1. Ensuring patient safety is a top priority, especially for a stage 3 Alzheimer's patient.
2. Restricting access to exits and stairways can prevent wandering and potential accidents.
3. This assessment is crucial for creating a safe environment for the patient.
4. Understanding the house design is essential for implementing appropriate safety measures.
Summary of other choices:
B. Understanding the prognosis is important but not as immediately critical as ensuring patient safety.
C. Knowing community resources is valuable but not as urgent as addressing safety concerns.
D. This choice is incorrect as assessing the house design for safety is crucial in this scenario.
In phobia fear of heights is referred to as
- A. Agoraphobia
- B. Acrophobia
- C. Abluntophobia
- D. Opiophobia
Correct Answer: B
Rationale: Acrophobia is the specific term for fear of heights, derived from Greek 'acro' (height) and 'phobos' (fear).