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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 daycare center for patients. During the evenings, members of the family care for the patient. One day, the nurse at the daycare center notices the patient's appearance is disheveled and that she has bruises on her wrists and back when escorted to the bathroom. 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 experiencing normal aging symptoms.
- D. The patient is suffering from a new medical condition.
Correct Answer: A
Rationale: The correct answer is A because the nurse's observations of disheveled appearance, bruises, and signs of physical abuse indicate possible neglect and abuse within the family. This is supported by the presence of Alzheimer's disease, vulnerability due to age, and the patient's living situation with family members who own a catering business. Choice B is incorrect as it does not explain the bruises and neglect observed. Choice C is incorrect as normal aging symptoms would not typically include bruises and neglect. Choice D is incorrect as there is no indication of a new medical condition causing these specific observations.
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A patient was admitted in a semistuporous catatonic state. Family states that the patient has neither left the apartment nor attended to personal hygiene for several weeks. The patient's last 48 hours have been spent lying in bed, mute and motionless. The nursing diagnosis that should be considered the priority is:
- A. self-care deficit.
- B. situational low self-esteem.
- C. disturbed thought processes.
- D. impaired verbal communication.
Correct Answer: A
Rationale: The correct answer is A: self-care deficit. The patient's symptoms indicate a lack of ability to perform self-care activities, which poses a risk to their health and well-being. This is a priority as addressing this issue will directly impact the patient's physical health and overall functioning. Situational low self-esteem (B) is not the priority as it focuses on the patient's emotional state rather than their immediate physical needs. Disturbed thought processes (C) and impaired verbal communication (D) may be present but are not the priority over the patient's inability to perform self-care activities.
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 for the client because it accurately reflects the client's behavior of isolation and lack of communication with peers, which are indicative of impaired social interaction.
Rationale:
1. Impaired social interaction is a key characteristic of schizoid personality disorder, as individuals with this disorder tend to be socially isolated and have difficulty forming relationships.
2. The client's behavior of not speaking to peers and sitting through meetings without interaction supports the diagnosis of impaired social interaction.
3. The description of the client by her mother as shy and having few friends further supports the diagnosis of impaired social interaction.
Summary:
A: Anxiety related to a new environment is incorrect because the client's behavior is more indicative of impaired social interaction rather than anxiety.
C: Ineffective coping related to new environment is incorrect as there is no evidence to suggest that the client is using maladaptive coping
Early manifestation of symptoms such as severe impairment in social interaction and in communication can be diagnosed as which of the following?
- A. Infantile autism
- B. Infantile amnesia
- C. Cerebral palsy
- D. Rett's syndrome
Correct Answer: A
Rationale: Infantile Autism: Early manifestations of Autistic Disorder symptoms, including impaired social interaction and communication.
The nurse is caring for a patient with anorexia nervosa. Which intervention is a priority?
- A. Establish a no-contact rule with the patient's family.
- B. Monitor the patient's food intake and weight closely.
- C. Encourage the patient to exercise to improve health.
- D. Focus primarily on addressing the patient's body image issues.
Correct Answer: B
Rationale: The correct answer is B because monitoring food intake and weight closely is crucial in managing anorexia nervosa to prevent further complications like malnutrition and dehydration. By closely monitoring these factors, the nurse can ensure the patient is receiving adequate nutrition and is not losing weight rapidly. Establishing a no-contact rule with the family (A) could hinder the patient's support system. Encouraging exercise (C) may worsen excessive calorie expenditure. Focusing on body image (D) is important but addressing immediate health risks takes precedence.
To cope with the devastating effects of schizophrenia and other serious mental illnesses, family members or significant others and clients will benefit most from:
- A. Regular psychoanalysis
- B. Intensive short-term therapy
- C. Ongoing treatment and support
- D. Continued medication adjustments
Correct Answer: C
Rationale: The correct answer is C: Ongoing treatment and support. This option is the most beneficial for coping with serious mental illnesses like schizophrenia because it involves long-term management and assistance. Ongoing treatment can include therapy, medication management, and support groups, which are crucial for helping individuals and their families manage symptoms and improve overall quality of life.
Explanation:
A: Regular psychoanalysis is not the most effective approach for managing the devastating effects of serious mental illnesses like schizophrenia. It may not provide the immediate support and intervention needed for crisis situations.
B: Intensive short-term therapy may offer temporary relief, but ongoing treatment and support are essential for long-term management and stability.
D: Continued medication adjustments are important, but they are just one aspect of a comprehensive treatment plan. Ongoing treatment and support encompass a broader range of interventions that are necessary for addressing the complex needs of individuals with serious mental illnesses.