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An elderly patient with dementia paces the hallway and often engages in wandering. The nurse documents that the patient is exhibiting which type of behavior that is characteristic of dementia?
- A. Passive behavior
- B. Functionally impaired behavior
- C. Involuntary psychomotor behavior
- D. Nonaggressive psychomotor behavior
Correct Answer: D
Rationale: The correct answer is D: Nonaggressive psychomotor behavior. In dementia, wandering and pacing are common behaviors due to cognitive impairment. Nonaggressive behavior refers to actions that do not involve harm or aggression towards others. The patient's behavior is voluntary and purposeless, indicating psychomotor involvement. Choices A, B, and C do not accurately describe the behavior exhibited by the patient with dementia. Passive behavior implies lack of engagement, functionally impaired behavior suggests difficulty performing activities of daily living, and involuntary psychomotor behavior implies actions beyond the patient's control, which are not the case in this scenario.
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Marie is 16 years old. She has been referred to the clinic by the nurse at her school because she started a fight with a younger girl and hurt her badly. The school nurse reports that Marie has been troublesome beforeskipping school, bullying, and smoking on school grounds on several occasions. Of the following, which diagnosis is most likely?
- A. Bipolar depression
- B. Paranoid schizophrenia
- C. Conduct disorder
- D. Dysthymic disorder
Correct Answer: C
Rationale: Conduct disorder is characterized by a pattern of aggressive behavior and violating the rights of others, including defiance and rule breaking. The other responses are psychiatric disorders that would not be the most likely diagnosis given Maries behavior.
A delusion is defined as seeing something that is not real
- A. TRUE
- B. FALSE
Correct Answer: B
Rationale: A delusion is a fixed false belief, not a perception (hallucination involves seeing/hearing something not real).
Which of the following procedures can be used to identify Down Syndrome pre-natally?
- A. Amniocentesis
- B. Amnioprolaxis
- C. Amniophalaxi
- D. Amniocalesis
Correct Answer: A
Rationale: Amniocentesis: A procedure extracting and analyzing amniotic fluid to identify Down Syndrome pre-natally in high-risk parents.
A client with catatonic schizophrenia has been posturing, standing with his left arm upraised and his right foot off the floor. For the most part, he ignores attempts at nursing intervention but will occasionally walk, sit, or lie down for a few minutes. The client eats standing up if the nurse brings a tray to the room. The priority nursing order would be to:
- A. Insist that client sit or lie down for 30 minutes hourly
- B. Assess for lower extremity edema bid
- C. Provide high-calorie drinks hourly
- D. Take client to activities therapy once daily
Correct Answer: B
Rationale: The correct answer is B. Assess for lower extremity edema bid.
Rationale:
1. Priority is to assess for lower extremity edema as the client is standing for extended periods, which can lead to edema.
2. Edema assessment is crucial for preventing complications like blood clots or skin breakdown.
3. Insisting on sitting or lying down may aggravate the client and worsen the situation.
4. Providing high-calorie drinks or activities therapy are not the immediate priority in this case.
In summary, assessing for lower extremity edema is crucial due to the client's prolonged standing, which can lead to potential health risks, making it the priority nursing order.
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. During the initial interview, what priority issue should the nurse address?
- A. Losses.
- B. Sleep patterns.
- C. School activities.
- D. None of the above.
Correct Answer: A
Rationale: The correct answer is A: Losses. The priority issue the nurse should address is the student's losses, such as the breakup with her boyfriend and the difficulty in making friends at the new university. This is important because these losses may be contributing to her emotional distress and maladaptive coping mechanisms like binge-eating and induced vomiting. The nurse needs to explore these losses to understand the root cause of the student's behavior and provide appropriate support.
Choice B: Sleep patterns, and Choice C: School activities are not the priority issues in this scenario. While sleep patterns and school activities are important aspects of the student's life, the primary concern here is addressing the emotional impact of the losses she has experienced.
Choice D: None of the above is incorrect because losses are indeed the priority issue that needs to be addressed in this situation. Ignoring the emotional impact of the student's losses could hinder the effectiveness of any interventions or support provided.