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A psychotic patient is delusional and has auditory hallucinations. The best statement to make when approaching the patient with an oral electronic thermometer would be:
- A. I need your vital signs. Put this in your mouth. This will not hurt.'
- B. I hope I can count on you to hold still while I take your temperature.'
- C. Please sit here while I take your temperature. I'll put the thermometer under your tongue for a few seconds.'
- D. This probe is only a thermometer that will tell us whether you have a fever. It will be all over in just a few seconds.'
Correct Answer: C
Rationale: The correct answer is C because it uses clear, simple language to explain the procedure to the patient. It acknowledges the patient's delusions by asking them to sit and calmly states the thermometer will be placed under their tongue. This approach is likely to minimize the patient's anxiety and increase cooperation.
Option A is incorrect as it may cause the patient to feel apprehensive due to the mention of "hurt." Option B is incorrect because it does not provide specific instructions about the procedure, which may lead to confusion for the patient. Option D is incorrect as it does not address the patient's delusions or provide clear instructions, potentially leading to increased resistance from the patient.
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An expected outcome for a client who hears voices telling him he is evil would be that by discharge, client will:
- A. Verbalize the reason the voices say he is evil
- B. Respond verbally to the voices
- C. Identify events that increase anxiety and promote hallucinations
- D. Integrate the voices into his personality structure in a positive manner
Correct Answer: C
Rationale: The correct answer is C because it focuses on addressing the underlying causes of the client's experience of hearing voices and feeling evil. By identifying events that increase anxiety and promote hallucinations, the client can work on reducing these triggers and managing his symptoms effectively. This approach is key for long-term improvement and recovery.
A: Verbalizing the reason the voices say he is evil does not address the root cause of the hallucinations and may not lead to effective coping strategies.
B: Responding verbally to the voices may not be therapeutic and could potentially reinforce the hallucinations.
D: Integrating the voices into his personality structure in a positive manner is not a recommended approach as it could lead to further distress and potentially harmful behaviors.
The population of Boston today is compared to its population after World War
- A. The same
- B. Slightly higher
- C. Considerably higher
- D. Less
Correct Answer: C
Rationale: Boston's population has grown considerably since post-World War II due to urban development and economic opportunities.
A newly admitted client has the diagnosis of catatonic schizophrenia. The nurse would expect to assess:
- A. Psychomotor symptoms
- B. Intense suspiciousness
- C. Inappropriate affect
- D. Clanging communication
Correct Answer: A
Rationale: Rationale:
A: Psychomotor symptoms are characteristic of catatonic schizophrenia, such as stupor or excessive motor activity.
B: Intense suspiciousness is more indicative of paranoid schizophrenia, not catatonic schizophrenia.
C: Inappropriate affect is a symptom seen in other types of schizophrenia but not specific to catatonic schizophrenia.
D: Clanging communication is associated with disorganized schizophrenia, not catatonic schizophrenia.
In catatonic schizophrenia, psychomotor symptoms like stupor, rigidity, or excitement are prominent.
The nurse performs a functional assessment of a client upon admission to a home health agency. The purpose of this assessment is to determine the client's:
- A. Level of consciousness.
- B. Ability to perform activities of daily living.
- C. Degree of reasoning, judgment, and thought processes.
- D. None of the above.
Correct Answer: B
Rationale: Rationale:
1. Functional assessment evaluates client's ability to perform ADLs.
2. Assessing ADLs helps determine client's independence level.
3. Independence in ADLs impacts care planning and interventions.
4. Level of consciousness (A) is related to neurological status, not functional ability.
5. Reasoning, judgment (C) are cognitive functions, not directly related to ADLs.
6. "None of the above" (D) excludes the correct purpose of functional assessment.
Anorexia nervosa is best described as a disorder that is potentially:
- A. serious.
- B. uncommon.
- C. psychiatric.
- D. life threatening.
Correct Answer: D
Rationale: The correct answer is D: life threatening. Anorexia nervosa is a serious eating disorder characterized by extreme restriction of food intake, leading to significant weight loss and potentially life-threatening consequences such as organ damage, heart problems, and even death. It is crucial to recognize the severity of anorexia nervosa as it can have devastating effects on physical and mental health. Choices A and C are partially correct, as anorexia nervosa is serious and psychiatric, but they do not fully capture the potential severity and life-threatening nature of the disorder. Choice B is incorrect as anorexia nervosa is not uncommon, affecting a significant number of individuals worldwide.