Nokea
A patient with the diagnosis of schizophrenia, disorganized type, approaches the nurse and says, 'It's beat, it's eat. No room for doom.' The nurse can correctly assess this verbalization as:
- A. neologisms.
- B. clanging.
- C. ideas of reference.
- D. associative looseness.
Correct Answer: B
Rationale: The correct answer is B: clanging. Clanging refers to the pattern of speech characterized by the association of words based on sound rather than meaning. In this case, the patient's verbalization, "It's beat, it's eat. No room for doom," demonstrates a connection based on rhyming sounds rather than coherent meaning. This is a classic example of clanging commonly seen in individuals with disorganized schizophrenia. Neologisms (choice A) refer to new words created by the individual, ideas of reference (choice C) involve believing that external events have special significance for oneself, and associative looseness (choice D) pertains to a lack of logical connection between thoughts. These choices are incorrect as they do not accurately describe the patient's speech pattern in this scenario.
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The nurse knows that stimulant medication for ADHD should be administered:
- A. At bedtime, to coincide with rising cortisol levels
- B. Only on school days to improve performance
- C. On an empty stomach
- D. With breakfast and lunch
Correct Answer: D
Rationale: Because these medications can contribute to insomnia, it is best to administer them earlier in the day with food. These are generally taken daily unless the doctor orders a drug holiday.
What is the most effective strategy for preventing relapse in a patient with anorexia nervosa?
- A. Providing a rigid, inflexible meal plan with strict weight goals.
- B. Offering therapy to address both physical and emotional factors.
- C. Encouraging the patient to lose weight to maintain control.
- D. Focusing on body image improvement before addressing nutrition.
Correct Answer: B
Rationale: The correct answer is B because offering therapy to address both physical and emotional factors is the most effective strategy for preventing relapse in a patient with anorexia nervosa. This approach helps the patient develop coping skills, explore underlying issues, and learn healthier ways to manage emotions and stress. By addressing both physical and emotional factors, the patient can build a strong support system, improve self-esteem, and work towards a sustainable recovery.
Choice A is incorrect because providing a rigid, inflexible meal plan with strict weight goals may increase anxiety and reinforce harmful behaviors associated with anorexia nervosa. Choice C is incorrect as encouraging the patient to lose weight to maintain control can perpetuate the disorder and increase the risk of relapse. Choice D is incorrect because focusing on body image improvement before addressing nutrition neglects the essential aspect of nutrition in recovery and may lead to distorted perceptions of health.
A 63-year-old female has been admitted to the hospital for cholecystitis. She is accompanied by her sister, who provides all the assessment data while the client sits and stares somewhat vacantly. You determine that the client is single, lives alone, and lost her job as a secretary last year when she was unable to learn a new computer system. The sister states she has recently had to manage the client's shopping, meal preparation, and finances. Which of the following are appropriate nursing diagnoses?
- A. Pain, self-care deficits, situational low self-esteem
- B. Anxiety, self-care deficits, disturbed thought processes
- C. Impaired home maintenance, disturbed thought process, impaired verbal communication
- D. Disturbed body image, anxiety, pain
Correct Answer: C
Rationale: The correct answer is C: Impaired home maintenance, disturbed thought process, impaired verbal communication.
Rationale:
1. Impaired home maintenance: The client is unable to take care of herself and her living environment due to the need for assistance in shopping, meal preparation, and finances.
2. Disturbed thought process: The client's vacant stare and inability to learn new tasks suggest cognitive impairment or confusion.
3. Impaired verbal communication: The client's lack of verbal interaction and reliance on her sister for assessment data indicate difficulties in expressing herself.
Summary:
A: Pain, self-care deficits, situational low self-esteem - Pain is not mentioned in the scenario, and the client's issues go beyond self-care deficits and low self-esteem.
B: Anxiety, self-care deficits, disturbed thought processes - While anxiety and disturbed thought processes may be present, impaired home maintenance and impaired verbal communication are more appropriate diagnoses based on the scenario.
D: Disturbed body image, anxiety, pain - Disturbed
A patient with fluctuating levels of awareness, confusion, and disorientation shouts, 'The bugs, they are crawling on my legs! Get them off me!' The nurse's inspections show that no bugs are present. The nurse can best assess this presentation as:
- A. Perseveration.
- B. Hypermetamorphosis.
- C. Tactile hallucinations.
- D. None of the above.
Correct Answer: C
Rationale: The correct answer is C: Tactile hallucinations. Tactile hallucinations involve the perception of physical sensations such as bugs crawling on the skin when no external stimuli are present. In this scenario, the patient's complaint of bugs crawling on their legs despite the nurse's inspection confirming the absence of bugs indicates a sensory hallucination, specifically a tactile one. This is different from perseveration (repetition of a particular response or activity) and hypermetamorphosis (excessive attention to environmental details). Choosing "None of the above" would not address the specific symptom of tactile hallucinations described in the patient's presentation.
In some countries, it is normal to defecate or urinate in public. This makes it clear that judgments of the normality of behavior are
- A. culturally relative
- B. statistical
- C. a matter of subjective discomfort
- D. related to conformity
Correct Answer: A
Rationale: Normality varies by culture, as behaviors acceptable in one society may be abnormal in another.