Nokea
A widowed patient tells a nurse that the door should be left unlocked because her husband will be coming home soon. Which response by the nurse would be most therapeutic?
- A. "You've forgotten that your husband's dead, haven't you?"Â
- B. "Just try to sleep. He won't be home for a long time yet."Â
- C. "You must miss him a lot. It almost seems he's here with you."Â
- D. "Your husband died 10 years ago. He won't be coming here."Â
Correct Answer: C
Rationale: The correct answer is C because it validates the patient's feelings without directly confronting or contradicting her belief. By acknowledging the patient's emotions and creating a sense of empathy, the nurse establishes a therapeutic rapport. Choice A is incorrect as it may be perceived as confrontational and insensitive. Choice B dismisses the patient's feelings and can be invalidating. Choice D is direct and may cause distress or confusion to the patient. In summary, option C is the best choice as it shows empathy and understanding towards the patient's emotional state.
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A 19-year-old client is admitted for the second time in 9 months and is acutely psychotic with a diagnosis of undifferentiated schizophrenia. The client sits alone rubbing her arms and smiling. She tells the nurse her thoughts cause earthquakes and that the world is burning. The nurse assesses the primary deficit associated with the client's condition as:
- A. Altered mood states
- B. Disturbed thinking
- C. Social isolation
- D. Poor impulse control
Correct Answer: B
Rationale: The correct answer is B: Disturbed thinking. In this scenario, the client's belief that her thoughts cause earthquakes and the world is burning are examples of delusions, which are a key symptom of schizophrenia. This demonstrates a disturbance in the client's thought process, indicating a primary deficit in thinking. Altered mood states (A) may be present as well but are not the primary deficit in this case. Social isolation (C) is a consequence of the client's symptoms rather than the primary deficit. Poor impulse control (D) is not the primary issue presented in the scenario.
A patient with schizophrenia is admitted to the psychiatric unit in an acutely disturbed, violent state. He is given several doses of haloperidol (Haldol) and becomes calm and approachable. During rounds the nurse notices the patient has his head rotated to one side in a stiffly fixed position. His lower jaw is thrust forward and he appears severely anxious. The patient has ______, and the nurse should ______.
- A. a dystonic reaction"¦administer PRN IM benztropine (Cogentin)
- B. tardive dyskinesia"¦seek a change in the drug or its dosage
- C. waxy flexibility"¦continue treatment with antipsychotic drugs
- D. akathisia"¦administer PRN diphenhydramine (Benadryl) PO
Correct Answer: A
Rationale: The correct answer is A: a dystonic reaction"¦administer PRN IM benztropine (Cogentin).
1. Step: Identify the symptoms - The patient has head rotation, stiff fixed position, and lower jaw thrust forward, indicating dystonia.
2. Step: Understand dystonic reactions - Dystonia is an extrapyramidal side effect of antipsychotic medications like haloperidol.
3. Step: Choose appropriate treatment - Benztropine is an anticholinergic medication used to treat acute dystonic reactions.
4. Step: Administer the medication - IM benztropine is the correct route for acute treatment of dystonia.
Summary:
- Choice B (tardive dyskinesia) is incorrect because the symptoms described are acute and not consistent with the gradual onset of tardive dyskinesia.
- Choice C (waxy flexibility) is incorrect because it is a symptom of catatonia, not a side effect of ant
The nurse in the Emergency Department is taking a history from a family accompanying a child with suspicious traumatic injuries. The nurse should:
- A. Obtain information as covertly as possible
- B. Avoid responding to hints that abuse has occurred
- C. Be open, concerned, and honest
- D. Separate the family from the child during the interview
Correct Answer: C
Rationale: The correct answer is C because being open, concerned, and honest fosters trust, encourages disclosure, and promotes a supportive environment for the family. This approach allows the nurse to gather necessary information effectively and ensure the safety and well-being of the child. Choice A is incorrect as covert behavior may lead to suspicion and hinder communication. Choice B is incorrect because ignoring hints of abuse can be detrimental to the child's safety. Choice D is incorrect as separating the family may escalate tension and prevent crucial information sharing.
Which of the following would indicate that a therapeutic activity program for a client with Alzheimer's disease had been successful? Client demonstrates:
- A. Accurate recent memory, positive emotional response, increased verbal expression
- B. Increased attention span, verbal expression of remote memory, positive emotional response
- C. Positive use of perseveration, reduction in use of habitual skills, improved abstract reasoning
- D. Positive emotional response, ability to remember multiple steps, accurate recent memory
Correct Answer: B
Rationale: The correct answer is B because increased attention span, verbal expression of remote memory, and positive emotional response indicate successful therapeutic program for Alzheimer's client. Attention span and verbal expression show cognitive improvement, while positive emotional response indicates overall well-being. Option A lacks improvement in remote memory. Option C mentions reduction in habitual skills, which is not desirable. Option D emphasizes recent memory and remembering multiple steps, but doesn't cover improvement in attention span or remote memory.
Consider these three drugs: divalproex (Depakote), carbamazepine (Tegretol), gabapentin (Neurontin). Which drug also belongs with this group?
- A. Clonazepam (Klonopin)
- B. Lamotrigine (Lamictal)
- C. Risperidone (Risperdal)
- D. Aripiprazole (Abilify)
Correct Answer: B
Rationale: The correct answer is B: Lamotrigine (Lamictal). All the drugs listed are commonly used in the treatment of epilepsy and mood disorders. Lamotrigine is often prescribed alongside divalproex, carbamazepine, and gabapentin as a mood stabilizer and antiepileptic medication. It works by stabilizing electrical activity in the brain and preventing seizures. Clonazepam (A) is a benzodiazepine used for anxiety and seizures, not in the same class as the other drugs. Risperidone (C) and Aripiprazole (D) are antipsychotics used for schizophrenia and bipolar disorder, not primarily for epilepsy.