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A patient with schizophrenia tells the nurse 'I don't know, it's just all the same. You never know. It comes, it goes, it blows away. Get it?' The best response for the nurse to make would be:
- A. Nothing you are saying is clear; you are not making sense.'
- B. Yes, life can be like that sometimes, very confusing.'
- C. Try to organize your thoughts and then tell me again.'
- D. I am having difficulty understanding what you are saying.'
Correct Answer: D
Rationale: The correct answer is D because it reflects active listening and acknowledges the patient's communication difficulties without being dismissive. By stating difficulty in understanding, the nurse shows empathy and openness to further clarification. Choice A is incorrect as it may be perceived as judgmental. Choice B is incorrect as it does not address the patient's communication challenges. Choice C is incorrect as it places the responsibility solely on the patient without offering support.
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A 14-year-old client on the eating disorders unit refuses to eat her meals and says to the nurse on the unit, 'You can't make me eat! There is nothing wrong with me.' The nurse will assess this as use of which defense mechanism?
- A. Repression.
- B. Rationalization.
- C. Sublimation.
- D. Denial.
Correct Answer: D
Rationale: The correct answer is D: Denial. Denial is a defense mechanism where an individual refuses to acknowledge reality to avoid discomfort. In this scenario, the client is denying the seriousness of their situation by refusing to eat and claiming there is nothing wrong. Repression (A) involves unconsciously blocking out unpleasant thoughts or feelings. Rationalization (B) is creating logical explanations to justify behavior. Sublimation (C) is redirecting negative impulses into positive behaviors. In this case, denial is the most fitting defense mechanism as the client is refusing to accept the reality of their eating disorder.
The physician prescribes haloperidol (Haldol), a first-generation antipsychotic drug, for a patient with schizophrenia who displays delusions, hallucinations, apathy, and social isolation. Which symptoms should most be monitored to evaluate the expected improvement from this medication?
- A. Talking to himself, belief that others will harm him
- B. Flat affect, avoidance of social activities, poor hygiene
- C. Loss of interest in recreational activities, alogia
- D. Impaired eye contact, needs help to complete tasks
Correct Answer: A
Rationale: The correct answer is A because the symptoms of delusions and hallucinations are key indicators of improvement in schizophrenia with antipsychotic treatment. These symptoms directly relate to the patient's perception of reality and are core features of the disorder. Monitoring these symptoms provides objective evidence of the medication's effectiveness in addressing the patient's psychotic symptoms.
Choices B, C, and D are incorrect because they mainly indicate negative symptoms of schizophrenia, such as flat affect, social withdrawal, and cognitive deficits. While monitoring these symptoms is important for assessing overall functioning and quality of life, they are not the primary target of improvement with antipsychotic medications. Symptoms like delusions and hallucinations are considered primary targets for evaluating the efficacy of antipsychotic treatment in schizophrenia.
Which of the following should the nurse consider when planning care for a client with antisocial personality disorder? Clients with antisocial personality disorder:
- A. Demand constant attention
- B. Tolerate frustration well
- C. Have well-developed superegos
- D. Are initially often charming
Correct Answer: D
Rationale: The correct answer is D: Are initially often charming. This is because individuals with antisocial personality disorder often exhibit charm and charisma to manipulate others for personal gain. This behavior is known as "charm offensive" and can be used to deceive and exploit others. This initial charm can make it difficult for others to recognize their true motives and manipulative nature.
Incorrect options:
A: Demand constant attention - Individuals with antisocial personality disorder may appear self-centered and manipulative but not necessarily demand constant attention.
B: Tolerate frustration well - Clients with antisocial personality disorder often have difficulty managing frustration and may resort to aggressive or impulsive behavior.
C: Have well-developed superegos - Individuals with antisocial personality disorder typically lack empathy and have a weak or underdeveloped superego, leading to a disregard for social norms and the rights of others.
A patient tells the nurse, 'I can't go to any unit meetings because when I get in that room, everyone can hear my thoughts.' The nurse can correctly assess this symptom as:
- A. concrete thinking.
- B. loose associations.
- C. thought broadcasting.
- D. auditory hallucinations.
Correct Answer: C
Rationale: The correct answer is C: thought broadcasting. This is when a person believes that others can hear their thoughts. In this scenario, the patient's belief that everyone in the unit meetings can hear their thoughts aligns with the symptom of thought broadcasting. It is a common manifestation of certain psychiatric disorders like schizophrenia.
Choice A, concrete thinking, refers to literal thinking without abstract reasoning and is not applicable in this context. Choice B, loose associations, involves disorganized and illogical thought patterns, which are not evident in the patient's statement. Choice D, auditory hallucinations, refers to hearing voices when no external stimulus is present, which is different from the patient's belief that others can hear their thoughts.
The nurse is to perform a complete assessment of a client in her home, using the Mini-Mental State Examination as one component. When the nurse arrives, the client is seated at the table with her husband, the TV is on, and several grandchildren are visiting. The client's husband says, 'Let's get on with this business.' The client is quiet, but her hands are gripped tightly, and she is staring at the ceiling. The best action for the nurse to take would be to:
- A. Explain to the husband that accurate data will be sought, and ask him to stay with the grandchildren in another room
- B. Explain the importance of the testing process and make an appointment for another day when the environment can be better controlled
- C. Not perform the test during the assessment (because it will not be valid) and rely on observations and reports from the family
- D. Ask the husband to make an appointment to bring his wife to the clinic for testing
Correct Answer: B
Rationale: The correct answer is B because conducting a Mini-Mental State Examination (MMSE) in a distracting environment with the client exhibiting signs of distress would likely yield inaccurate results. By explaining the importance of the testing process and rescheduling for a quieter day, the nurse ensures a more accurate assessment. This allows for a controlled environment conducive to obtaining reliable data.
Choice A is incorrect because simply moving the husband and grandchildren to another room may not eliminate distractions or address the client's distress, potentially still impacting the accuracy of the assessment.
Choice C is incorrect as relying solely on observations and reports from the family may not provide a comprehensive assessment of the client's cognitive function, as the MMSE is a standardized tool designed for objective evaluation.
Choice D is incorrect as it does not address the immediate issue of conducting the assessment in a more suitable environment and may disrupt the client's routine by requiring a clinic visit.