Nokea
After 1 week of continuous mental confusion, an elderly African American client is
admitted with a preliminary diagnosis of a neurocognitive disorder due to dementia.
Which statement would cause the nurse to question this diagnosis?
- A. There has been no triiodothyronine or thyroxine level evaluation ordered
- B. Neurocognitive disorders do not typically occur in African American clients
- C. The symptoms presented are more indicative of parkinsonism
- D. Dementia does not develop suddenly
Correct Answer: D
Rationale:
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Before discharge from the chemical dependency unit, clients are introduced to different community resources. Which of the following resources would be best for a teenage client, who has been abusing over-the-counter sedatives and is ready for discharge in two days?
- A. Detoxification center
- B. Home care
- C. Assertive community team
- D. Twelve-step recovery group
Correct Answer: A
Rationale: For a teenage client who has been abusing over-the-counter sedatives and is ready for discharge in two days, the best resource would be a detoxification center. This specialized facility can provide the necessary medical and psychological support to safely manage the withdrawal symptoms associated with substance abuse. It is crucial to ensure a safe and supervised detox process for the client's well-being and successful recovery.
Which medication would the nurse least likely use to provide immediate intervention for an angry psychotic client?
- A. Lithium
- B. Alprazolam
- C. Diphenhydramine
- D. Haloperidol
Correct Answer: B
Rationale: Alprazolam is a benzodiazepine commonly used for anxiety disorders. While it may help calm an individual, it is not typically the first-line choice for managing acute agitation in a psychotic client. Haloperidol, on the other hand, is a typical antipsychotic medication often used for immediate intervention in psychiatric emergencies involving aggression or psychosis.
A client is diagnosed with somatic symptom disorder. Which question will help the nurse develop nursing diagnoses for this client's plan of care?
- A. Are you satisfied with your appearance?
- B. Do you take medication for anxiety as prescribed?
- C. When did you last feel detached from your environment?
- D. How long have you had these memory problems?
Correct Answer: B
Rationale: In clients with somatic symptom disorder, it is crucial to assess their adherence to medication for anxiety as prescribed. This question helps the nurse understand the client's treatment compliance, which can impact the development of nursing diagnoses and the overall plan of care. Monitoring medication adherence is essential in managing the client's symptoms and improving outcomes.
In a center for women who have been abused, which intervention would the nurse use for a woman whose husband has been abusing her for several years?
- A. Often times you don't need help, you just need to know when to go
- B. Under these circumstances, leaving your husband is the decision to make
- C. This must be very painful for you. We are here to help you
- D. Let's talk about your strengths. You have them, but sometimes they get lost in pain
Correct Answer: C
Rationale: Choice C is the most appropriate intervention when working with a woman who has been abused by her husband. It acknowledges the woman's pain, expresses empathy, and offers support, creating a safe space for her to open up and seek help. This response shows understanding and compassion, which are crucial when dealing with individuals experiencing abuse.
The client recently survived a plane crash and is assessed by the nurse. Which client statement would cause the nurse to suspect that the client may be experiencing PTSD?
- A. I believe that I was meant to survive this accident so that I can focus on the important things in life
- B. Although I have nightmares sometimes, I have started going to church to show gratitude for surviving the crash
- C. I am so afraid that I will never be able to fly again, but I know that it will take a while
- D. I keep having these thoughts about the crash that just pop into my mind at random times
Correct Answer: D
Rationale: Experiencing intrusive thoughts about a traumatic event, such as a plane crash, that occur unexpectedly and repeatedly is a common symptom of Post-Traumatic Stress Disorder (PTSD). These thoughts can be distressing and are often a key indicator of PTSD. Options A, B, and C demonstrate coping mechanisms and fears related to the traumatic event but do not specifically address the hallmark symptom of intrusive thoughts. Therefore, option D is the correct choice as it aligns with a potential symptom of PTSD.