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An individual brought by ambulance to the emergency room is accompanied by a roommate. The patient fights against the restraints and shouts incoherently. The roommate reports that the patient was weak and confused on awakening this morning and about 3 hours ago began "rambling and talking crazy."Â A nurse notes that the patient's skin is flushed and dry. The priority nursing action is to:
- A. take the patient's vital signs.
- B. start intravenous fluids.
- C. administer a sedative.
- D. perform a mental status examination.
Correct Answer: A
Rationale: The correct answer is A: take the patient's vital signs. This is the priority action because the patient is exhibiting signs of potential medical emergency, such as altered mental status, flushed and dry skin, and confusion. Vital signs can provide crucial information about the patient's condition and help determine the urgency of the situation. Starting intravenous fluids (B) may be necessary but should be based on the assessment of vital signs first. Administering a sedative (C) is not appropriate without knowing the underlying cause of the symptoms. Performing a mental status examination (D) is important but not the priority in this situation where the patient's physical condition needs immediate attention.
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A patient with fluctuating levels of awareness, confusion, and disorientation shouts, 'The bugs, they are crawling on my legs! Get them off me!' The nurse's inspections show that no bugs are present. The nurse can best assess this presentation as:
- A. Perseveration.
- B. Hypermetamorphosis.
- C. Tactile hallucinations.
- D. None of the above.
Correct Answer: C
Rationale: The correct answer is C: Tactile hallucinations. Tactile hallucinations involve the perception of physical sensations such as bugs crawling on the skin when no external stimuli are present. In this scenario, the patient's complaint of bugs crawling on their legs despite the nurse's inspection confirming the absence of bugs indicates a sensory hallucination, specifically a tactile one. This is different from perseveration (repetition of a particular response or activity) and hypermetamorphosis (excessive attention to environmental details). Choosing "None of the above" would not address the specific symptom of tactile hallucinations described in the patient's presentation.
A client seen by the rape crisis nurse 1 month after the incident states, 'I'm confused and just not myself. I have mood swings during the day, and I have nightmares at night. Sometimes I think I'm going crazy.' Other times, she is just plain afraid to be alone. The nurse should assess the client for:
- A. Trauma syndrome.
- B. Post-traumatic stress disorder.
- C. Acute stress disorder.
- D. None of the above.
Correct Answer: A
Rationale: The correct answer is A: Trauma syndrome. This choice is correct because the client's symptoms of confusion, mood swings, nightmares, feeling like they are going crazy, and fear of being alone align with the criteria for trauma syndrome. This syndrome encompasses a range of symptoms that occur after experiencing a traumatic event, such as rape.
Choice B: Post-traumatic stress disorder (PTSD) is not the best option in this case because the client's symptoms are more indicative of acute distress and confusion rather than the criteria for a formal diagnosis of PTSD, which typically requires the persistence of symptoms over time.
Choice C: Acute stress disorder is also not the most appropriate choice because while some symptoms may align, the duration and specific criteria for this disorder may not fully match the client's presentation.
Choice D: None of the above is incorrect as trauma syndrome best fits the client's symptoms based on the information provided.
Which one of the following definitions is incorrect?
- A. Delusions – A fixed false belief not based in reality
- B. Mental illness – A condition affecting thinking, mood, or behavior
- C. Obsessive-compulsive disorder – A disorder with intrusive thoughts and repetitive behaviors
- D. Obsessive-compulsive disorder – A disorder with intrusive thoughts and repetitive behaviors
Correct Answer: C
Rationale: An illusion is actually a misinterpretation of a real stimulus, not the perception of something that does not exist. The incorrect definition given in option D confuses an illusion with a hallucination, which is a false sensory perception without an external stimulus.
A school-aged patient with attention-deficit hyperactivity disorder (ADHD) is displaying disruptive behaviors at home. The psychiatric-mental health nurse modifies the treatment plan for the social domain, by advising the patient's parents to:
- A. establish eye contact before giving directions
- B. initiate a point system, to reward the patient for appropriate behavior
- C. instruct the patient to work on one homework assignment at a time
- D. maintain a predictable environment in the home
Correct Answer: B
Rationale: A point system reinforces positive behavior, directly addressing social disruptiveness in ADHD.
A client with obsessive-compulsive personality disorder is described by other staff as being perfectionistic, inflexible, and a 'master at procrastination.' The nurse learns that the client is nearly immobilized during times that call for the client to make a decision. The nurse realizes that the most likely hypothesis is this behavior is related to:
- A. A need to make others uncomfortable
- B. Needing to be the center of attention
- C. Wanting someone else to be responsible
- D. Fear of making a mistake
Correct Answer: D
Rationale: The correct answer is D: Fear of making a mistake. This is the most likely hypothesis because individuals with obsessive-compulsive personality disorder often have an intense fear of making errors or mistakes. This fear can lead to excessive preoccupation with details, perfectionism, and procrastination. The client's immobilization during decision-making moments is likely due to the overwhelming anxiety and fear of making the wrong choice, which is a common trait in individuals with this disorder.
Choice A (A need to make others uncomfortable) is incorrect because there is no indication that the client's behavior is driven by a desire to cause discomfort to others. Choice B (Needing to be the center of attention) is incorrect as individuals with obsessive-compulsive personality disorder typically focus more on their own perfectionism rather than seeking attention. Choice C (Wanting someone else to be responsible) is incorrect as this behavior is more about the individual's fear of making mistakes rather than avoiding responsibility.