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 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 pattern of words that rhyme or have similar sounds but lack coherent meaning. This is characteristic of clanging seen in disorganized schizophrenia. Neologisms (A) are newly created words with unique meanings, which is not evident here. Ideas of reference (C) involve misinterpreting unrelated events as being personally significant, which is not demonstrated in the patient's statement. Associative looseness (D) is a thought disorder where ideas are loosely associated, but the patient's statement does not show this specific feature.
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A nurse is working with a patient with bulimia nervosa. Which outcome would indicate successful intervention?
- A. The patient eats three full meals daily without purging.
- B. The patient agrees to begin psychotherapy without resistance.
- C. The patient loses 5% of their body weight over 3 months.
- D. The patient expresses improved body image but still purges occasionally.
Correct Answer: A
Rationale: The correct answer is A because it indicates successful intervention in bulimia nervosa by demonstrating healthy eating behavior without purging. This outcome reflects improved control over binge-purge cycles and supports physical health. Choices B and D show progress but do not directly address the core issue of purging behavior. Choice C, losing weight, can be a misleading indicator and may not necessarily reflect improved psychological and behavioral outcomes associated with recovery from bulimia nervosa.
A patient with swelling and a laceration above the right eye states, 'I don't know what caused me to fall and cut my head on the door frame in my bedroom. I'm lucky my spouse was home to take me to the hospital.' The patient's spouse appears nervous but smiles when mentioning that the patient is 'so clumsy at times.' Which nursing intervention should the nurse give priority attention to when addressing this patient's needs?
- A. Provide a thorough assessment that includes a focus on signs of old injuries.
- B. Interview the patient regarding the circumstances surrounding this suspicious fall.
- C. Directly ask the patient if spousal abuse is occurring or has ever occurred.
- D. Notify security that there is a possibility that this patient is a victim of physical abuse.
Correct Answer: A
Rationale: The correct answer is A: Provide a thorough assessment that includes a focus on signs of old injuries. This is the priority intervention because the patient's statement, combined with the spouse's behavior, raises suspicion of potential domestic abuse. By assessing for signs of old injuries, the nurse can gather crucial information to determine if the patient is a victim of abuse.
Choice B: Interview the patient regarding the circumstances surrounding this suspicious fall may be important, but assessing for signs of old injuries takes priority as it provides concrete evidence of potential abuse.
Choice C: Directly ask the patient if spousal abuse is occurring or has ever occurred is necessary, but the patient may not feel comfortable disclosing abuse directly. Assessing for old injuries can provide objective evidence.
Choice D: Notify security that there is a possibility that this patient is a victim of physical abuse is premature without concrete evidence. Assessing for old injuries should be done first to gather information before taking further action.
A patient with Alzheimer's disease has been determined to have a dressing/grooming self-care deficit. Which intervention(s) would be appropriate for this nursing diagnosis? Select all that apply.
- A. Replace personal clothing with gym clothes that all match each other.
- B. Label the patient's clothing with his name and name of the item.
- C. Provide clothing with elastic waistbands and hook-and-loop closures.
- D. None of the above.
Correct Answer: A
Rationale: Rationale: Option A is correct because replacing personal clothing with matching gym clothes simplifies dressing, reducing confusion for a patient with Alzheimer's. This intervention promotes independence and minimizes frustration. Labeling clothing (Option B) may help in identifying items but does not address the deficit. Clothing with elastic waistbands and closures (Option C) may be helpful but does not directly address the deficit. "None of the above" (Option D) is incorrect as Option A is an appropriate intervention.
An 85-year-old client with dementia has a nursing diagnosis of Self-care deficit: bathing, hygiene. She lives at home and has not bathed for a month. Her 67-year-old daughter states that she thinks her mother may have forgotten how to take a shower. An appropriate outcome would be that the client will:
- A. Bathe daily with reminders
- B. Bathe twice weekly with assistance
- C. Allow the nurse to totally manage hygiene
- D. Remain free of skin diseases/lesions
Correct Answer: B
Rationale: The correct answer is B: Bathe twice weekly with assistance. This outcome is appropriate because it takes into account the client's dementia and self-care deficit while also promoting hygiene and independence. Daily bathing may be overwhelming for the client and may not be necessary for maintaining good hygiene. Allowing the nurse to totally manage hygiene (choice C) may not promote the client's independence. Remaining free of skin diseases/lesions (choice D) is important but may not directly address the self-care deficit. Bathe twice weekly with assistance strikes a balance between promoting hygiene and respecting the client's abilities and limitations.
A patient diagnosed with dementia associated with excessive alcohol use is shown a pencil, a nickel, and a safety pin and asked to repeat the names of each. Later when asked to identify the same three items the patient is unable to do so. The nurse assesses this as:
- A. apraxia.
- B. agnosia.
- C. concreteness.
- D. catastrophizing.
Correct Answer: B
Rationale: The correct answer is B: agnosia. Agnosia is the inability to recognize or identify objects despite intact sensory abilities. In this case, the patient's inability to identify the pencil, nickel, and safety pin suggests a deficit in object recognition, which aligns with agnosia.
A: Apraxia is the inability to perform purposeful movements despite intact motor function, not related to object recognition.
C: Concreteness refers to difficulty understanding abstract concepts, not object recognition.
D: Catastrophizing is an irrational belief that something is far worse than it actually is, not related to the patient's inability to identify objects.