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A patient with schizophrenia who admits to auditory hallucinations anxiously tells the nurse, 'The voice is telling me to do things.' Which of the following responses should the nurse make next?
- A. Do you recognize the voice you hear?'
- B. How long has this been happening?'
- C. Does what the voice tells you to do frighten you?'
- D. What is the voice telling you to do?'
Correct Answer: D
Rationale: The correct answer is D: "What is the voice telling you to do?" This response helps the nurse assess the content and potential danger of the hallucinations, guiding further interventions. Option A focuses on recognition, which is less urgent. Option B addresses duration, not immediate safety. Option C inquires about fear but does not directly address the hallucination's content. By asking what the voice commands, the nurse gains crucial insight for risk assessment and safety planning.
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A patient with paranoid personality disorder is noted to sit alone in a corner of the unit living room. When anyone approaches, the patient is haughty or simply ignores the other person. When staff invite her to join an activity, she tells them, 'I do not care to be with people who do not like me.' A nursing diagnosis that should be considered is:
- A. splitting.
- B. activity intolerance.
- C. powerlessness.
- D. impaired social interaction.
Correct Answer: D
Rationale: The correct answer is D: impaired social interaction. This patient's behavior of sitting alone, being haughty, and refusing to engage with others indicates difficulty in social interactions. The patient's belief that others do not like her also suggests social challenges. Impaired social interaction relates to difficulty in establishing or maintaining relationships.
A: Splitting is a defense mechanism where the patient views people as all good or all bad, which is not evident in this scenario.
B: Activity intolerance refers to insufficient physiological or psychological energy to endure or complete required or desired daily activities. This does not apply here.
C: Powerlessness refers to the perception of lack of control over a situation, which is not the primary issue in this case.
A patient with anorexia nervosa is resistant to weight gain. What is the rationale for establishing a contract with the patient to participate in measures to produce a specified weekly weight gain?
- A. Severe anxiety concerning eating is expected, so objective and subjective data are needed.
- B. Patient involvement in decision-making increases sense of control and promotes collaboration.
- C. The patient's family is not supportive of the treatment plan.
- D. None of the above.
Correct Answer: B
Rationale: Correct Answer: B - Patient involvement in decision-making increases sense of control and promotes collaboration.
Rationale:
1. Involving the patient in decision-making empowers them and increases their sense of control over their treatment.
2. Collaborating with the patient fosters a positive therapeutic relationship.
3. This approach is more likely to lead to better treatment adherence and outcomes.
Summary:
A: While objective and subjective data are important, this choice does not address the need for patient involvement in decision-making and collaboration.
C: The lack of family support is not directly related to the rationale for establishing a contract with the patient.
D: This choice is incorrect as patient involvement is crucial in promoting successful treatment outcomes.
The outcome that should be established for an elderly patient with delirium caused by fever and dehydration is that the patient will:
- A. Return to a premorbid level of functioning.
- B. Demonstrate motor responses to noxious stimuli.
- C. Identify stressors negatively affecting self.
- D. None of the above.
Correct Answer: A
Rationale: The correct answer is A because the goal in managing delirium in an elderly patient is to restore them to their premorbid level of functioning. This involves addressing the underlying causes like fever and dehydration. Option B is incorrect as it focuses on a neurological response rather than the overall outcome for the patient. Option C is also incorrect as it pertains to identifying stressors, which is not the primary goal in managing delirium. Option D is incorrect as it dismisses the importance of restoring the patient to their baseline level of functioning.
A patient with an eating disorder states, 'Now that I've gained 4 pounds, I can't wear shorts until I lose it again.' The nurse documents that the patient is exhibiting which cognitive distortion related to maladaptive eating regulation responses?
- A. Magnification
- B. Superstitious thinking
- C. Personalization
- D. Dichotomous thinking
Correct Answer: A
Rationale: The correct answer is A: Magnification. This cognitive distortion involves exaggerating the significance of a negative event, in this case, gaining 4 pounds. The patient's focus on this small weight gain as a major obstacle to wearing shorts reflects magnification. Superstitious thinking (B) involves believing in unrelated events causing outcomes, which is not evident here. Personalization (C) involves taking responsibility for events beyond one's control, which is not the case in this scenario. Dichotomous thinking (D) involves seeing things in black and white terms, which is not demonstrated in the patient's statement.
Sleep terrors usually occur only once a night, during stages 3 and 4 of NREM sleep. They are often accompanied by which physical sign?
- A. Intense stress.
- B. Sexual arousal.
- C. Physical strength.
- D. None of the above.
Correct Answer: D
Rationale: The correct answer is D: None of the above. Sleep terrors are not typically accompanied by intense stress, sexual arousal, or increased physical strength. Sleep terrors are characterized by sudden awakening from sleep with intense fear and a physical reaction, such as screaming or thrashing. These episodes occur during stages 3 and 4 of NREM sleep and are not associated with the physical signs mentioned in the other choices. Therefore, the correct answer is D, as sleep terrors do not necessarily involve any of the physical signs listed in the other options.