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A patient with schizophrenia is experiencing auditory hallucinations. Which nursing intervention is most appropriate?
- A. Encourage the patient to ignore the voices.
- B. Provide a structured and safe environment.
- C. Engage the patient in a debate about the reality of the voices.
- D. Ask the patient to describe the content of the hallucinations.
Correct Answer: D
Rationale: The most appropriate nursing intervention when a patient with schizophrenia is experiencing auditory hallucinations is to ask the patient to describe the content of the hallucinations. This intervention helps assess the risk associated with the hallucinations and provides valuable insight into the patient's condition, aiding in developing an effective care plan. Encouraging the patient to ignore the voices (Choice A) may not address the underlying issues or risks associated with the hallucinations. Providing a structured and safe environment (Choice B) is important but does not directly address the hallucinations. Engaging the patient in a debate about the reality of the voices (Choice C) may worsen the situation by invalidating the patient's experiences.
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A patient with generalized anxiety disorder (GAD) is prescribed venlafaxine. The nurse should educate the patient about which potential side effect?
- A. Hypertension
- B. Hypotension
- C. Bradycardia
- D. Hyperglycemia
Correct Answer: A
Rationale: The correct answer is A: Hypertension. Venlafaxine, an SNRI, can lead to hypertension as a side effect. This medication can cause an increase in blood pressure, particularly at higher doses. Educating the patient about this potential adverse effect is crucial to enhance awareness and monitoring for any signs or symptoms of elevated blood pressure. Choices B, C, and D are incorrect because venlafaxine is more likely to cause hypertension rather than hypotension, bradycardia, or hyperglycemia.
When assessing a patient with major depressive disorder, which symptom would most likely be observed?
- A. Euphoria
- B. Anhedonia
- C. Increased energy
- D. Racing thoughts
Correct Answer: B
Rationale: Anhedonia, the inability to feel pleasure in activities that were once enjoyable, is a hallmark symptom of major depressive disorder. Patients with major depressive disorder often experience a pervasive feeling of emptiness and loss of interest in activities they used to find pleasurable. Euphoria, increased energy, and racing thoughts are more commonly associated with conditions like bipolar disorder rather than major depressive disorder.
Which therapeutic intervention is most effective for social anxiety disorder?
- A. Group therapy
- B. Behavioral rehearsal
- C. Cognitive-behavioral therapy
- D. Medication management
Correct Answer: C
Rationale: Cognitive-behavioral therapy (CBT) is considered the most effective therapeutic intervention for social anxiety disorder. CBT helps individuals identify and change negative thought patterns and behaviors associated with anxiety, leading to long-term symptom relief and improved coping strategies. Group therapy (choice A) can be beneficial as a complementary approach but may not be as effective as CBT for directly targeting individual cognitive and behavioral patterns. Behavioral rehearsal (choice B) is a technique used within CBT and not a standalone intervention for social anxiety disorder. Medication management (choice D) can be used as an adjunct to therapy in some cases but is not the first-line treatment for social anxiety disorder.
When assessing a patient with schizophrenia who exhibits flat affect and social withdrawal, these symptoms are classified as:
- A. Positive symptoms
- B. Negative symptoms
- C. Cognitive symptoms
- D. Mood symptoms
Correct Answer: B
Rationale: Flat affect and social withdrawal are characteristic of negative symptoms in schizophrenia. Negative symptoms involve disruptions to normal emotions and behaviors, such as reduced emotional expression (flat affect) and social withdrawal. These symptoms reflect a decrease or absence of normal functions. Positive symptoms, on the other hand, involve the presence of abnormal behaviors or experiences, such as hallucinations and delusions, which are added to a person's experiences. Cognitive symptoms relate to difficulties with thinking, memory, and processing information, impacting cognition. Mood symptoms involve disturbances in mood regulation, which is distinct from the flat affect seen in negative symptoms.
A patient with major depressive disorder is prescribed a selective serotonin reuptake inhibitor (SSRI). The nurse should educate the patient about which potential side effect?
- A. Hypertension
- B. Diarrhea
- C. Sexual dysfunction
- D. Weight gain
Correct Answer: C
Rationale: Corrected Rationale: Selective serotonin reuptake inhibitors (SSRIs) are commonly associated with sexual dysfunction as a side effect. This adverse effect includes decreased libido, delayed orgasm, and erectile dysfunction. Educating patients about this potential side effect is crucial to manage expectations and consider appropriate interventions. Choices A, B, and D are incorrect as SSRIs are not typically associated with hypertension, diarrhea, or weight gain as common side effects.