Nokea
A young patient diagnosed with schizophrenia is standing naked after showering and appears to be both dazed and indecisive. The nursing intervention that will be most helpful to promote dressing would be:
- A. saying, 'These are your clothes. Please get dressed.'
- B. saying, 'These are your underpants. I'll help you put them on.'
- C. asking, 'Which of these two outfits would you like to wear now?'
- D. asking, 'Is something the matter with your clothes that makes you not want to dress?'
Correct Answer: B
Rationale: The correct answer is B. By saying, "These are your underpants. I'll help you put them on," the nurse provides clear guidance and offers assistance, which can help the patient feel more comfortable and supported in the dressing process. This approach acknowledges the patient's need for help while respecting their autonomy.
Choice A is too directive and may make the patient feel pressured or overwhelmed. Choice C involves too many options, which can be confusing for a patient experiencing indecisiveness. Choice D assumes a problem with the clothes rather than focusing on the patient's needs and feelings. Overall, choice B is the most appropriate and supportive intervention in this situation.
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Which of the following is a common emotional response for patients with anorexia nervosa?
- A. Fear of gaining weight and loss of control over eating.
- B. Lack of concern about food intake and weight.
- C. Excessive joy and pride in achieving weight loss.
- D. Denial of the need for treatment and weight restoration.
Correct Answer: A
Rationale: The correct answer is A because fear of gaining weight and loss of control over eating are core features of anorexia nervosa. Patients with anorexia often have an intense fear of gaining weight, leading to restrictive eating behaviors. This fear is accompanied by a sense of loss of control over their eating habits.
Choice B is incorrect because lack of concern about food intake and weight is not a common emotional response in anorexia nervosa. Choice C is incorrect as excessive joy and pride in achieving weight loss are more characteristic of other eating disorders like bulimia nervosa or orthorexia. Choice D is incorrect because denial of the need for treatment and weight restoration may be present in some cases but is not a common emotional response in anorexia nervosa.
A 10-year-old boy is diagnosed with gender dysphoria. Which assessment finding would the nurse expect?
- A. Having tea parties with dolls
- B. A compromised sexual response cycle
- C. Identifying with boys who are athletic
- D. Intense urges to watch his parents have sex
Correct Answer: A
Rationale: The correct answer is A because a child with gender dysphoria may display behaviors that align with the gender they identify with, such as engaging in activities typically associated with that gender. Tea parties with dolls may indicate the child's preference for activities stereotypically linked to girls, indicating a mismatch between their assigned gender and gender identity. Choices B, C, and D are incorrect as they do not align with typical assessment findings for gender dysphoria in children. B is more related to sexual dysfunction, C is a common behavior for all children, and D is inappropriate and unrelated to the diagnosis of gender dysphoria.
Schizophrenia is most commonly found in
- A. adolescents
- B. young adults
- C. the middle aged
- D. the elderly
Correct Answer: B
Rationale: Schizophrenia typically emerges in young adulthood, often in the late teens to early 20s.
A client who is diagnosed with schizoid personality disorder is isolative, does not speak to her peers, and sits through the community meeting without speaking. Her mother describes her as shy and having few friends. Which would be an appropriate nursing diagnosis for this client?
- A. Anxiety related to a new environment as evidenced by isolation and not talking with peers
- B. Impaired social interaction related to unfamiliar environment as evidenced by isolation and not talking with peers
- C. Ineffective coping related to new environment as evidenced by isolation and minimal interaction with others
- D. Disturbed thought processes related to a new environment as evidenced by isolation and minimal interactions with others
Correct Answer: B
Rationale: The correct answer is B: Impaired social interaction related to unfamiliar environment as evidenced by isolation and not talking with peers. This is the most appropriate nursing diagnosis because schizoid personality disorder is characterized by a pattern of social detachment and limited emotional expression. The client's behavior of isolating herself and not engaging with peers aligns with impaired social interaction.
Choice A (Anxiety) is incorrect because the client's behavior is more indicative of social detachment rather than anxiety. Choice C (Ineffective coping) is incorrect as there is no evidence to suggest the client is using maladaptive coping strategies. Choice D (Disturbed thought processes) is incorrect as the client's presentation does not indicate any disturbances in thought processes, but rather a lack of social engagement.
A student transfers from a hometown college to a university 200 miles away after breaking up with her boyfriend of 2 years. She was slow to make friends at the university. The history shows a close relationship with her mother and sister. She began eating large quantities when she felt sad, and then she induced vomiting. When the student's schoolwork declined, she sought help from the university health clinic. During the initial interview, what priority issue should the nurse address?
- A. Losses
- B. Sleep patterns
- C. School activities
- D. Menstrual flow
Correct Answer: A
Rationale: The correct answer, Losses (choice A), should be the priority issue for the nurse to address during the initial interview with the student. The rationale is as follows:
1. **Emotional Impact of Breakup**: The student's recent breakup is a significant loss that can trigger emotional distress.
2. **Social Isolation**: Slow to make friends at the university could indicate feelings of loneliness and isolation, further exacerbating the impact of the breakup.
3. **Eating Disorder Behaviors**: Eating large quantities and inducing vomiting are maladaptive coping mechanisms linked to emotional distress and loss.
4. **Academic Decline**: The decline in schoolwork could be a manifestation of the student's emotional struggles related to loss.
5. **Relationship with Family**: Close relationship with her mother and sister may also influence how she copes with losses and seeks support.
Summary:
- **Sleep Patterns (choice B)**: While important, sleep patterns are secondary to addressing the student's emotional distress and coping mechanisms related