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A severely withdrawn patient diagnosed with schizophrenia will spend time in the dayroom but will not speak to staff or to other patients. The most therapeutic nursing intervention in response to this behavior would be to:
- A. seat the patient with a group of patients who are talking to each other.
- B. ignore the silence and talk about superficial topics such as the weather.
- C. point out that the patient makes others uncomfortable by refusing to speak.
- D. plan time for staff members to sit with the patient even though the patient does not talk with them.
Correct Answer: D
Rationale: The correct answer is D because it focuses on building a therapeutic relationship with the patient without placing pressure on them to speak. By planning time for staff members to sit with the patient, even if the patient does not talk, it allows for nonverbal communication and presence to convey support and care. This approach respects the patient's boundaries and allows them to engage at their own pace, fostering trust and a sense of safety.
Choice A is incorrect as it may overwhelm the patient by placing them in a social situation they are not ready for. Choice B is incorrect as discussing superficial topics does not address the patient's underlying issues. Choice C is incorrect as it may make the patient feel judged or pressured to speak, further isolating them.
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The family of a patient with schizophrenia who has been stable for a year reports to the community mental health nurse that the patient reports feeling tense and having difficulty concentrating. He sleeps only 3 to 4 hours nightly and has begun to talk about creatures called 'volmers' hiding in the warehouse where he works and undoing his work each night. This information most likely suggests:
- A. medication nonadherence.
- B. a need for psychoeducation.
- C. the chronic nature of his illness.
- D. relapse of his schizophrenia.
Correct Answer: D
Rationale: The correct answer is D: relapse of his schizophrenia. The patient's symptoms of feeling tense, difficulty concentrating, poor sleep, and delusional beliefs about creatures at work indicate a worsening of his psychotic symptoms. This suggests a relapse of schizophrenia, a chronic mental illness characterized by periods of stability and exacerbation of symptoms. The patient's previous stability for a year makes medication nonadherence less likely. While psychoeducation may be beneficial, the patient's current symptoms require more immediate intervention for relapse management. The information provided does not directly indicate the chronic nature of his illness, but rather an acute exacerbation. Therefore, D is the most appropriate choice based on the presented symptoms and clinical understanding of schizophrenia.
A patient with anorexia nervosa is at risk for refeeding syndrome. The nurse should be most concerned with:
- A. Hyperglycemia.
- B. Electrolyte imbalances, particularly hypophosphatemia.
- C. Increased hunger and overeating.
- D. Rapid weight gain and hypertension.
Correct Answer: B
Rationale: The correct answer is B: Electrolyte imbalances, particularly hypophosphatemia. Refeeding syndrome occurs when a malnourished individual receives nutrition too quickly, leading to shifts in electrolytes like phosphate, potassium, and magnesium. Hypophosphatemia is a key concern due to its potential to cause cardiac and respiratory failure. Hyperglycemia (A) may occur but is not the primary concern. Increased hunger and overeating (C) are common symptoms of anorexia nervosa but not directly related to refeeding syndrome. Rapid weight gain and hypertension (D) are potential consequences of refeeding but are not the immediate concern compared to electrolyte imbalances.
An older adult patient who lives with a daughter and attends the Alzheimer day hospital program exhibits bilateral bruising for the second time on both upper outer arms. When the nurse questions the patient about the bruising, the patient starts to cry and pleads, 'Please don't say anything. It's not my daughter's fault. I just bruise easily.' Which intervention reflects the best management of this situation?
- A. Call the daughter to discuss both the bruising and her parent's reaction.
- B. Report the elder abuse, and inform the patient and the daughter of your intention.
- C. Notify the patient's social worker of the bruising after a complete assessment has been completed.
- D. Inform the patient and the daughter of your intention to document the bruising and arrange for appropriate counseling.
Correct Answer: B
Rationale: The correct answer is B: Report the elder abuse and inform the patient and the daughter of your intention. This is the best intervention as it prioritizes the safety and well-being of the older adult. Here's the rationale:
1. The patient's repeated bruising and fear of disclosure indicate potential abuse.
2. Reporting elder abuse is mandatory to ensure protection for the patient.
3. Informing the patient and daughter shows transparency and involves them in the process.
4. It is crucial to address the situation promptly to prevent further harm.
Summary:
A: Calling the daughter may escalate the situation and compromise the patient's safety.
C: Notifying the social worker without addressing the abuse directly may delay necessary action.
D: Counseling may be beneficial, but addressing the abuse is a priority to ensure the patient's safety.
A 65-year-old woman has a two-year history of mucous diarrhoea due to a large villous adenoma of the rectum. She is also taking digoxin and diuretics for chronic congestive failure. Which of the following investigations would be the most helpful prior to surgery?
- A. Serum chloride.
- B. Serum digoxin.
- C. Serum calcium.
- D. Serum potassium.
Correct Answer: D
Rationale: Villous adenomas cause potassium loss via diarrhea, and diuretics exacerbate this, risking hypokalemia, which is dangerous with digoxin (toxicity risk). Serum potassium (D) is critical pre-surgery.
An 82-year-old widow with Alzheimer's disease lives with her daughter's family, which owns a catering business. During the week, the patient attends a day care center for patients with dementia. During the evenings, members of the family care for the patient. One day, the nurse at the day care center notices the patient's appearance is disheveled and that she startles easily. She has a strong odor of urine, and her hair is uncombed. When the nurse escorts the patient to the bathroom, she notices bruises on her wrists and back. What most likely explains the nurse's observations?
- A. The patient is being neglected and abused within the family.
- B. The dementia is progressing, reducing self-care and increasing falls.
- C. The patient is being inadequately cared for, resulting in accidents.
- D. The patient has developed delirium, resulting in poor hygiene and injuries.
Correct Answer: A
Rationale: The correct answer is A: The patient is being neglected and abused within the family. The nurse's observations of the patient's disheveled appearance, strong odor of urine, uncombed hair, and bruises indicate signs of neglect and abuse. Here's the rationale:
1. Disheveled appearance and strong odor of urine suggest lack of personal care.
2. Uncombed hair signals neglect in grooming.
3. Bruises on wrists and back are indicative of physical abuse.
4. Startling easily may be due to fear or anxiety from abuse.
In summary, the other choices (B, C, D) are incorrect because they do not account for the combination of neglect, poor hygiene, and physical injuries seen in the patient, which are more indicative of abuse and neglect within the family.