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A patient with schizophrenia has received typical (first-generation) antipsychotics for a year. His hallucinations are less intrusive, but he remains apathetic, has poverty of thought, cannot work, and is socially isolated. To address these symptoms, the nurse might consult the prescribing health care provider to suggest a change to:
- A. haloperidol (Haldol).
- B. olanzapine (Zyprexa).
- C. diphenhydramine (Benadryl).
- D. chlorpromazine (Thorazine).
Correct Answer: B
Rationale: The correct answer is B: olanzapine (Zyprexa). Olanzapine is an atypical (second-generation) antipsychotic that is known to be effective in treating negative symptoms of schizophrenia, such as apathy, poverty of thought, and social withdrawal. These symptoms are often resistant to typical antipsychotics like haloperidol (A) and chlorpromazine (D), which are more effective for positive symptoms like hallucinations. Diphenhydramine (C) is an antihistamine and not used to treat schizophrenia symptoms. In summary, olanzapine is the best choice to address the specific symptoms described in the scenario.
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A 27-year-old woman diagnosed with borderline personality disorder displays a labile affect, impulsivity, frequent angry outbursts, and difficulty tolerating her angry feelings without self-injury. A priority nursing diagnosis for this client is:
- A. Anxiety
- B. Risk for self-mutilation
- C. Risk for other-directed violence
- D. Ineffective coping
Correct Answer: B
Rationale: The correct answer is B: Risk for self-mutilation. This is the priority nursing diagnosis because the client is displaying behaviors such as self-injury due to difficulty tolerating angry feelings. Self-mutilation poses an immediate risk to the client's safety and requires immediate intervention. The other choices are incorrect because anxiety (A) is a common symptom of borderline personality disorder but not the priority in this case. Risk for other-directed violence (C) is not indicated as the client is primarily harming themselves. Ineffective coping (D) is a broad diagnosis that does not address the immediate risk of self-mutilation.
What is the most important aspect of nursing care for patients with anorexia nervosa during refeeding?
- A. Refeed the patient with high-calorie foods quickly to gain weight.
- B. Start with small, manageable portions and gradually increase caloric intake.
- C. Restrict food choices to healthy foods only.
- D. Encourage the patient to take food supplements in addition to meals.
Correct Answer: B
Rationale: The correct answer is B: Start with small, manageable portions and gradually increase caloric intake. This approach is essential because refeeding syndrome can occur in patients with anorexia nervosa, where rapid refeeding can lead to severe electrolyte imbalances and potentially life-threatening complications. Starting with small portions helps to prevent this syndrome by allowing the body to gradually adjust to increased caloric intake. Additionally, it helps in preventing overwhelming the patient with large amounts of food, which can trigger anxiety and resistance to eating.
Incorrect choices:
A: Refeed the patient with high-calorie foods quickly to gain weight - This can lead to refeeding syndrome and is not a safe approach.
C: Restrict food choices to healthy foods only - Restricting food choices can exacerbate disordered eating behaviors and does not address the need for gradual refeeding.
D: Encourage the patient to take food supplements in addition to meals - While supplements can be helpful, they should not be a primary focus over balanced
Which behavior would the nurse expect to observe in a person who commits psychic rape?
- A. The perpetrator gives money to the patient after the rape.
- B. The perpetrator seduces the patient by providing wine, flowers, and music.
- C. The perpetrator threatens the patient to submit or else be severely beaten.
- D. The perpetrator mentions always including violent bondage in sexual activities.
Correct Answer: D
Rationale: The correct answer is D because mentioning violent bondage in sexual activities indicates a pattern of behavior associated with psychic rape, where the perpetrator exerts control and inflicts harm on the victim. This choice aligns with the power dynamics and manipulation typically seen in cases of psychic rape.
A: Giving money after the rape does not necessarily indicate psychic rape and is more characteristic of bribery or transactional behavior.
B: Seduction with wine, flowers, and music may indicate manipulation but does not specifically relate to the psychological violation inherent in psychic rape.
C: Threatening the patient with violence is a form of physical coercion rather than psychic rape, which involves psychological manipulation and violation.
The nurse performs a functional assessment of a client upon admission to a home health service. The purpose of this assessment is to determine the client's:
- A. Level of consciousness
- B. Ability to perform activities of daily living
- C. Degree of reasoning, judgment, and thought processes
- D. Level of functioning memory
Correct Answer: B
Rationale: The correct answer is B: Ability to perform activities of daily living. A functional assessment in home health services focuses on evaluating the client's ability to independently perform daily tasks such as bathing, dressing, and preparing meals. This assessment helps determine the client's level of independence and need for assistance. Choices A, C, and D are incorrect because they do not directly assess the client's ability to perform activities of daily living, which is the primary purpose of a functional assessment in this context.
An elderly female client on the mental unit suddenly becomes upset because she can't remember where she is and she says, 'I can't think straight.' The staff has never witnessed this behavior in the client, and this type of complaint is not documented in the nursing history. What is the client most likely experiencing?
- A. Hallucinations
- B. Dementia
- C. Delusions
- D. Delirium
Correct Answer: D
Rationale: The correct answer is D: Delirium. Delirium is characterized by sudden onset confusion, disorientation, and impaired cognitive function. In this scenario, the elderly client's sudden confusion and inability to think straight suggest an acute change in mental status, which is indicative of delirium. Delirium is often triggered by underlying medical conditions or medications.
A: Hallucinations involve perceiving things that are not real, which is not described in the scenario.
B: Dementia is a chronic condition with gradual cognitive decline, not sudden onset confusion.
C: Delusions are fixed false beliefs, which are not mentioned in the scenario.
In summary, the client is most likely experiencing delirium due to the sudden onset of confusion and cognitive impairment, which is not consistent with hallucinations, dementia, or delusions.