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A patient with schizophrenia tells the nurse, 'Everyone must listen to me. I am the redeemer. I will bring peace to the world.' From this the nurse can determine that an appropriate nursing diagnosis is:
- A. Disturbed sensory perception: auditory.
- B. Risk for other-directed violence.
- C. Chronic low self-esteem.
- D. Nonadherence: medication.
Correct Answer: C
Rationale: Step 1: The patient's statement indicates grandiosity and delusions of grandeur, common in schizophrenia.
Step 2: Chronic low self-esteem is a common nursing diagnosis for those with grandiose delusions.
Step 3: The patient's belief of being the redeemer suggests underlying feelings of inadequacy.
Step 4: Addressing self-esteem can help the patient cope with such delusions.
Summary: A is incorrect as there is no mention of auditory hallucinations. B is incorrect as there is no immediate threat of violence. D is incorrect as nonadherence to medication is not evident in the scenario.
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An 83-year-old man becomes lost while driving. He pulls into a driveway to turn around and cannot figure out how to put his car in reverse, so he drives into the yard, makes a circle, and drives back out of the driveway. He is stopped by police, who take him to the emergency department. The physician diagnoses him with Alzheimer's disease and refers him to the neurology clinic for follow-up. Given this diagnosis, which behaviors should the clinic nurse anticipate?
- A. Does not know today's date.
- B. Unable to shower without help.
- C. Denial of mental impairment.
- D. None of the above.
Correct Answer: A
Rationale: The correct answer is A: Does not know today's date. This behavior is commonly associated with Alzheimer's disease due to memory impairment. The inability to recall the current date is a key symptom of cognitive decline. In this case, the man's difficulty with reversing his car and getting lost are indicative of cognitive impairment.
Choice B, Unable to shower without help, is a functional impairment and not specific to Alzheimer's disease. Choice C, Denial of mental impairment, may occur in some individuals with Alzheimer's but is not a consistent behavior. Choice D, None of the above, is incorrect as memory deficits, such as not knowing the date, are commonly seen in Alzheimer's disease.
A respected school coach was arrested after a student reported the coach attempted to have sexual contact. Which nursing action has priority in the period immediately following the coach's arrest?
- A. Determine the nature and extent of the coach's sexual disorder.
- B. Assess the coach's potential for suicide or other self-harm.
- C. Assess the coach's self-perception of problem and needs.
- D. Determine whether other children were harmed.
Correct Answer: B
Rationale: The correct answer is B: Assess the coach's potential for suicide or other self-harm. This is the priority nursing action because the coach may be experiencing intense emotional distress and may be at risk for harming themselves. By assessing for suicidal ideation or self-harm, the nurse can ensure the coach's safety and provide appropriate interventions if needed.
Choice A is incorrect because determining the nature and extent of the coach's sexual disorder is not the priority at this moment. Choice C is also incorrect as assessing the coach's self-perception of the problem and needs can be addressed after ensuring their immediate safety. Choice D is incorrect as determining whether other children were harmed is important but not the priority immediately following the coach's arrest.
A 35-year-old woman who is being interviewed by the advanced practice nurse indicates that she has few friends, fears criticism from others, and withholds information about her thoughts and feelings because she anticipates a negative reaction. Based on these data, the nurse suspects that Sarah may later be diagnosed as having:
- A. Borderline personality disorder
- B. Histrionic personality disorder
- C. Avoidant personality disorder
- D. Schizoid personality disorder
Correct Answer: C
Rationale: The correct answer is C: Avoidant personality disorder. This is because the woman's fear of criticism, reluctance to share thoughts and feelings, and limited social interactions are characteristic of avoidant personality disorder. Individuals with this disorder have intense feelings of inadequacy, fear of rejection, and avoid situations where they may be criticized or judged.
Choice A: Borderline personality disorder is not the correct answer because individuals with borderline personality disorder typically have unstable relationships, impulsivity, and a fear of abandonment.
Choice B: Histrionic personality disorder is not the correct answer as individuals with this disorder seek attention and exhibit dramatic and attention-seeking behavior, which is not indicated in the scenario.
Choice D: Schizoid personality disorder is not the correct answer as individuals with this disorder tend to have a limited range of emotional expression and lack interest in forming social relationships, which does not align with the woman's fear of criticism and desire to avoid negative reactions.
A useful strategy for helping a patient with schizophrenia manage a potential relapse is to:
- A. have the patient attend group therapy.
- B. advise the patient to continue taking medication daily.
- C. teach the patient and family about behaviors that indicate impending relapse.
- D. schedule appointments for blood tests to determine serum medication levels.
Correct Answer: C
Rationale: The correct answer is C because teaching the patient and family about behaviors indicating an impending relapse helps in early detection and intervention. This empowers them to recognize warning signs like changes in behavior or mood, allowing for prompt action.
Choice A (group therapy) may be beneficial for support but does not directly address relapse prevention. Choice B (medication adherence) is crucial but not specific to relapse management. Choice D (blood tests) is important for monitoring medication levels but does not focus on recognizing relapse indicators.
When a patient diagnosed with paranoid schizophrenia was discharged from the unit 6 months ago, the plan was for him to take chlorpromazine (Thorazine), a conventional (first generation) antipsychotic medication, 300 mg po daily. He tells the nurse he stopped taking his pills after a few months because they made him feel like a 'zombie.' What other common side effects should the nurse determine if the patient experienced?
- A. Sweating, nausea, and weight gain
- B. Sedation, tremor, and muscle stiffness
- C. Headache, watery eyes, and runny nose
- D. Mild fever, sore throat, and skin rash
Correct Answer: B
Rationale: The correct answer is B: Sedation, tremor, and muscle stiffness. These side effects are commonly associated with conventional antipsychotic medications like chlorpromazine. Sedation is a common side effect that can make the patient feel drowsy or sluggish. Tremors are involuntary muscle movements that can affect the hands, arms, or legs. Muscle stiffness can cause rigidity and difficulty moving smoothly. These side effects are known to impact the quality of life and may contribute to the patient feeling like a 'zombie.'
Choices A, C, and D are incorrect because they do not align with the common side effects of conventional antipsychotic medications. Sweating, nausea, and weight gain (Choice A) are not typical side effects of chlorpromazine. Headache, watery eyes, and runny nose (Choice C) are more commonly associated with allergies or cold symptoms rather than antipsychotic medications. Mild fever, sore throat, and skin rash (Choice D)