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An outpatient diagnosed with schizophrenia attends programming at a community mental health center. The patient says, I threw away the pills because they keep me from hearing God. Which response by the nurse would most likely to benefit this patient?
- A. You need your medicine. Your schizophrenia will get worse without it.
- B. Do you want to be hospitalized again? You must take your medication.
- C. I would like you to come to the medication education group every Thursday.
- D. I noticed that when you take the medicine, you have been able to hold a job you wanted.
Correct Answer: D
Rationale: Connecting medication to the patient's goal (job) (D) motivates adherence despite desirable hallucinations. Exhortations (A, B) ignore insight issues, and education (C) assumes a knowledge deficit, not the core problem.
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An 85-year-old client with dementia has a nursing diagnosis of Self-care deficit: bathing, hygiene. She lives at home and has not bathed for a month. Her 67-year-old daughter states that she thinks her mother may have forgotten how to take a shower. An appropriate outcome would be that the client will:
- A. Bathe daily with reminders
- B. Bathe twice weekly with assistance
- C. Allow the nurse to totally manage hygiene
- D. Remain free of skin diseases/lesions
Correct Answer: B
Rationale: The correct answer is B: Bathe twice weekly with assistance. This outcome is appropriate because it takes into account the client's dementia and self-care deficit while also promoting hygiene and independence. Daily bathing may be overwhelming for the client and may not be necessary for maintaining good hygiene. Allowing the nurse to totally manage hygiene (choice C) may not promote the client's independence. Remaining free of skin diseases/lesions (choice D) is important but may not directly address the self-care deficit. Bathe twice weekly with assistance strikes a balance between promoting hygiene and respecting the client's abilities and limitations.
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 from the university health clinic. During the initial interview, what priority issue should the nurse address?
- A. Losses
- B. Sleep patterns
- C. School activities
- D. Menstrual flow
Correct Answer: A
Rationale: The correct answer is A: Losses. The priority issue the nurse should address is the student's recent breakup and difficulty making friends, which are significant losses impacting her emotional well-being. By addressing these losses, the nurse can help the student process her emotions and develop coping strategies.
B: Sleep patterns may be affected by the student's emotional distress, but it is a secondary concern compared to addressing the underlying losses.
C: School activities are important, but the root cause of the student's decline in schoolwork is likely related to her emotional state following the breakup.
D: Menstrual flow is not the priority issue at this time as it is not directly related to the student's emotional struggles and academic decline.
True paranoids are rarely treated or admitted to hospitals because
- A. they are potentially harmful and dangerous to others
- B. they resist the attempts of others to offer help
- C. their severe hallucinations make reasoning with them impossible
- D. psychiatric hospitals are primarily for psychotics
Correct Answer: B
Rationale: Paranoid individuals' mistrust leads them to resist help, reducing treatment rates.
A patient with Alzheimer's disease has been determined to have a dressing/grooming self-care deficit. Which intervention(s) would be appropriate for this nursing diagnosis? Select all that apply.
- A. Replace personal clothing with gym clothes that all match each other.
- B. Label the patient's clothing with his name and name of the item.
- C. Provide clothing with elastic waistbands and hook-and-loop closures.
- D. None of the above.
Correct Answer: A
Rationale: Rationale: Option A is correct because replacing personal clothing with matching gym clothes simplifies dressing, reducing confusion for a patient with Alzheimer's. This intervention promotes independence and minimizes frustration. Labeling clothing (Option B) may help in identifying items but does not address the deficit. Clothing with elastic waistbands and closures (Option C) may be helpful but does not directly address the deficit. "None of the above" (Option D) is incorrect as Option A is an appropriate intervention.
What is the most important aspect of refeeding for a patient with anorexia nervosa?
- A. Refeeding should begin slowly to avoid complications.
- B. Rapid weight gain is essential to restore health.
- C. The patient should be encouraged to make independent food choices.
- D. Fluid intake should be restricted to avoid water retention.
Correct Answer: A
Rationale: The correct answer is A because refeeding should start slowly to prevent refeeding syndrome, a potentially life-threatening condition caused by rapid electrolyte shifts. Gradually increasing caloric intake allows the body to adjust and reduces the risk of complications. Rapid weight gain (B) is not recommended as it can lead to medical complications. Encouraging independent food choices (C) may not be suitable initially as structured meal plans are often necessary. Restricting fluid intake (D) is not advisable as adequate hydration is crucial during refeeding.