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 79-year-old white male tells a nurse, 'I have felt very sad lately. I do not have much to live for. My family and friends are all dead, and my own health is failing.' The nurse should analyze this comment as
- A. normal pessimism of the elderly.
- B. evidence of risks for suicide.
- C. a call for sympathy.
- D. normal grieving.
Correct Answer: B
Rationale: The correct answer is B: evidence of risks for suicide. The elderly man's statement indicates feelings of hopelessness, loneliness, and lack of purpose, which are common risk factors for suicide in older adults. The nurse should assess further for suicidal ideation and intervene accordingly.
Choice A is incorrect because the statement goes beyond normal pessimism by expressing thoughts of not having much to live for. Choice C is incorrect as the statement is more indicative of distress rather than a mere call for sympathy. Choice D is incorrect as normal grieving typically involves processing emotions related to a specific loss, whereas the man's statement reflects a broader sense of despair.
A nurse is caring for a patient who has a maladaptive response to eating regulation. The patient tells the nurse, 'I know my parents are already upset, but I need to lose another 10 pounds to be at an ideal weight.' This statement suggests that the best treatment setting for this patient would be:
- A. the hospital.
- B. an outpatient program.
- C. a day treatment program.
- D. at home with weekly nursing visits.
Correct Answer: A
Rationale: The correct answer is A: the hospital. This patient's maladaptive eating behavior and desire to lose more weight despite concerns from family indicate a serious condition requiring intensive care and monitoring. In the hospital, the patient can receive immediate medical attention, nutritional support, and psychological intervention to address underlying issues. Outpatient programs (B) may not offer sufficient supervision, while day treatment programs (C) may not provide round-the-clock care. Home with weekly nursing visits (D) is not appropriate for a patient with such severe eating regulation issues.
Asking the husband to leave is likely to increase the client's anxiety and alter test results. Testing in the more familiar, comfortable surroundings of the home will yield more reliable results.
- A. Asking the husband to leave is likely to increase the client's anxiety and alter test results because the presence of a loved one can provide comfort and support during a potentially stressful situation.
- B. Testing in the more familiar, comfortable surroundings of the home will yield more reliable results because the client is in a setting where they feel safe and secure, which can help reduce anxiety and promote accurate test outcomes.
- C. Both A and B.
- D. None of the above.
Correct Answer: C
Rationale: The correct answer is C because both statements A and B provide valid reasons supported by psychological principles. Statement A is correct as the presence of a loved one can indeed provide comfort and support, reducing anxiety and potentially improving test outcomes. Statement B is also accurate as testing in familiar surroundings can help the client feel safe and secure, leading to more reliable results. Therefore, combining these two factors - the presence of a loved one and testing in a comfortable environment - would likely yield the most reliable results by addressing both emotional and environmental factors impacting the client's anxiety levels during the test.
A worker is characterized by her co-workers as 'painfully shy' and lacking in self-confidence. Her co-workers say she stays in her cubicle all day, never coming out for breaks or lunch. One day after falling on the ice in the parking lot, she goes to the nurse's office, where she apologizes for falling and mentions that she hopes the company will not fire her for being so clumsy. Which nursing approach or response would be most therapeutic?
- A. Remain professional and a bit detached so as not to arouse suspiciousness on her part.
- B. Reassure her that many others have fallen at work and not ever been criticized or fired.
- C. Acknowledge her concerns in a matter-of-fact manner and provide first aid as needed.
- D. Explain that an incident report about her fall will go to a manager who will contact her.
Correct Answer: B
Rationale: The correct answer is B because it focuses on reassurance and empathy, which are important in therapeutic communication. By reassuring the worker that others have fallen without facing negative consequences, the nurse is validating her feelings and reducing her anxiety. This approach helps build trust and rapport, essential for effective communication and support.
Choices A, C, and D are incorrect because they do not address the worker's emotional needs or provide the reassurance she requires. Option A suggests remaining detached, which may come across as uncaring. Option C focuses solely on providing first aid and does not acknowledge the worker's concerns. Option D introduces the fear of potential consequences without providing any reassurance or emotional support, which could increase the worker's anxiety.
The persistent eating of nonfood items such as clay, laundry starch, insects, leaves, or pebbles that lasts for longer than 1 month is called:
- A. pica.
- B. bulimia.
- C. rumination.
- D. regurgitation.
Correct Answer: A
Rationale: Sure! The correct answer is A: pica. Pica is the persistent consumption of nonfood items lasting longer than 1 month. This condition is characterized by cravings for non-nutritive, nonfood substances. Bulimia (B) is a different eating disorder involving binge eating followed by purging behaviors. Rumination (C) is the repeated regurgitation and rechewing of food. Regurgitation (D) is the act of bringing swallowed food back to the mouth without nausea or retching.