Nokea
An expected outcome for a client who hears voices telling him he is evil would be that by discharge, client will:
- A. Verbalize the reason the voices say he is evil
- B. Respond verbally to the voices
- C. Identify events that increase anxiety and promote hallucinations
- D. Integrate the voices into his personality structure in a positive manner
Correct Answer: C
Rationale: The correct answer is C because it focuses on addressing the underlying causes of the client's experience of hearing voices and feeling evil. By identifying events that increase anxiety and promote hallucinations, the client can work on reducing these triggers and managing his symptoms effectively. This approach is key for long-term improvement and recovery.
A: Verbalizing the reason the voices say he is evil does not address the root cause of the hallucinations and may not lead to effective coping strategies.
B: Responding verbally to the voices may not be therapeutic and could potentially reinforce the hallucinations.
D: Integrating the voices into his personality structure in a positive manner is not a recommended approach as it could lead to further distress and potentially harmful behaviors.
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Explain four (4) the behavioral features of Anorexia Nervosa
- A. Restricting food intake
- B. Excessive exercise
- C. Body image distortion
- D. Fear of weight gain
Correct Answer: A
Rationale: These behaviors reflect the core features of anorexia: restriction, overactivity, distorted perception, and weight obsession.
A 45-year-old married woman who works full time in a factory has recently been absent for 3-day periods on several occasions. Each time, she returned to work wearing dark glasses. Facial and body bruises were apparent. Her supervisor became suspicious that she was a victim of battering and referred her to the occupational health nurse. What should the nurse first focus on as she meets the patient?
- A. Notifying the police of the abuse
- B. Documenting the woman's injuries
- C. Establishing trust and building rapport
- D. Collecting evidence to prosecute the abuser
Correct Answer: C
Rationale: The correct answer is C: Establishing trust and building rapport. The nurse should first focus on building a trusting relationship with the patient to create a safe environment for her to disclose any abuse she may be experiencing. By establishing trust and rapport, the nurse can gain the patient's confidence and encourage her to open up about her situation. This approach is crucial in ensuring the patient feels supported and empowered to seek help.
Incorrect choices:
A: Notifying the police of the abuse - This may jeopardize the patient's safety and could worsen the situation if she is not ready to involve law enforcement.
B: Documenting the woman's injuries - While documenting injuries is important, it should not be the first step as it may further distress the patient without addressing the underlying issue.
D: Collecting evidence to prosecute the abuser - Prosecution should not be the initial focus; the priority should be on the patient's well-being and safety.
A patient was admitted to the mental health unit after arguing with co-workers and threatening to kill them. He is diagnosed with paranoid schizophrenia. On the unit he is aloof and suspicious. He mentioned that two physicians he saw talking were plotting to kill him. On the basis of data gathered at this point, which two primary nursing diagnoses should the nurse consider?
- A. Disturbed thought processes and Risk for other-directed violence
- B. Spiritual distress and Social isolation
- C. Risk for loneliness and Knowledge deficit
- D. Disturbed personal identity and Nonadherence
Correct Answer: A
Rationale: The correct answer is A: Disturbed thought processes and Risk for other-directed violence.
1. Disturbed thought processes: The patient's delusion of being plotted against by the physicians indicates impaired thought processes typical of paranoid schizophrenia.
2. Risk for other-directed violence: The patient's threatening behavior towards co-workers suggests a potential for violent acts towards others due to his paranoid beliefs.
Summary of why other choices are incorrect:
B: Spiritual distress and Social isolation are not primary concerns given the patient's acute symptoms of paranoia and risk for violence.
C: Risk for loneliness and Knowledge deficit are not crucial at this point as the patient's primary issues are related to paranoia and violence.
D: Disturbed personal identity and Nonadherence are not relevant to the immediate safety and mental health concerns presented by the patient.
Which of the following is classified as a mood disorder?
- A. bipolar disorder
- B. multiple personality disorder
- C. delusional disorder
- D. dissociative disorder
Correct Answer: A
Rationale: Bipolar disorder, with its mood swings, is a classic mood disorder.
Which intervention is appropriate for a patient who has anorexia nervosa and is resisting weight gain?
- A. Assist the patient to identify triggers to binge eating.
- B. Provide remedial consequences for weight loss.
- C. Assess for signs of impulsive eating.
- D. Explore needs for health teaching.
Correct Answer: A
Rationale: The correct answer is A because assisting the patient to identify triggers to binge eating is crucial in addressing the resistance to weight gain in anorexia nervosa. By understanding the triggers, the patient can work on overcoming them and develop healthier eating habits. Option B is incorrect as providing remedial consequences for weight loss may exacerbate the issue. Option C is incorrect as impulsive eating is not the main concern in anorexia nervosa. Option D is incorrect as exploring needs for health teaching does not directly address the resistance to weight gain in anorexia nervosa.