Nokea
Behavioral problems in which the person exhibits symptoms suggesting physical disease or injury, but for which there is no identifiable cause, are called
- A. mood disorders
- B. schizophrenia
- C. organic brain pathologies
- D. somatoform disorders
Correct Answer: D
Rationale: Somatoform disorders feature physical complaints without medical explanation.
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A newly admitted patient with schizophrenia approaches the unit nurse and says, 'The voices are bothering me. They are yelling and telling me stuff. They are really bad.' Which response by the nurse would be most appropriate?
- A. Do you hear these voices very often?'
- B. Do you have a plan for getting away from the voices?'
- C. I'll stay with you. Tell me what you are hearing.'
- D. Try to ignore them and play cards with the others.'
Correct Answer: C
Rationale: The correct answer is C because it demonstrates active listening and empathy, which can help establish trust and rapport with the patient. By saying, "I'll stay with you. Tell me what you are hearing," the nurse acknowledges the patient's distress and offers support. This response can help the patient feel heard and understood, which is crucial in managing symptoms of schizophrenia.
Choice A is incorrect as it focuses more on the frequency rather than addressing the immediate distress. Choice B is incorrect as it assumes the patient has a plan to escape the voices, which may not be the case and can escalate the situation. Choice D is incorrect as it dismisses the patient's experience and suggests distraction rather than addressing the underlying issue.
The home care nurse assessed a client with a history of dementia who had a herniorrhaphy at an ambulatory surgical center the previous day. The client lives in a senior living facility. The client thinks he is in the army and that it is 1945. The nurse should:
- A. Reorient the client to the current time and place.
- B. Notify the client's family of the confusion.
- C. Document the client's confusion and disorientation.
- D. None of the above.
Correct Answer: A
Rationale: The correct answer is A: Reorient the client to the current time and place. The nurse should reorient the client to prevent distress and promote safety. This approach helps the client feel more secure and may reduce confusion. Choice B is incorrect because the nurse should address the client's needs first. Choice C is not enough on its own as the nurse needs to actively assist the client. Choice D is incorrect as action is needed in this situation to support the client.
A student nurse visiting a senior center says, 'It's depressing to see these old people. They are weak and frail. I doubt any of them can engage in a discussion.' The student is expressing
- A. reality
- B. ageism
- C. empathy
- D. vulnerability
Correct Answer: B
Rationale: The correct answer is B: ageism. The student nurse's statement demonstrates prejudice and discrimination based on age. Ageism is the negative stereotypes, prejudice, and discrimination against individuals or groups based on their age. In this case, the student is making assumptions about the abilities and worth of older individuals solely based on their age. The statement does not reflect reality, as not all older people are weak or unable to engage in meaningful discussions. The other choices are incorrect as the statement is not reflective of reality (A), empathy (C), or vulnerability (D).
A nurse observes a patient who is sitting alone in a room put hands over both ears and vigorously shake her head as though saying, 'No.' Later the patient cries and mutters, 'You don't know what you're talking about! Leave me alone.' What assessment should the nurse attempt to validate?
- A. The patient is seeking the attention of staff.
- B. The patient is inappropriately expressing emotion.
- C. The patient is experiencing auditory hallucinations.
- D. The patient is displaying negative symptoms of schizophrenia.
Correct Answer: C
Rationale: The correct answer is C: The patient is experiencing auditory hallucinations. The patient's behavior of covering both ears and shaking her head as if responding to voices, along with muttering and crying, suggests a sensory perception that is not based on external stimuli. This aligns with the characteristic symptoms of auditory hallucinations, which are common in conditions like schizophrenia.
Choice A is incorrect because the patient's behavior is not necessarily seeking attention but rather responding to internal stimuli. Choice B is incorrect as the patient's emotional expression seems to be a result of the auditory hallucinations rather than being inappropriate. Choice D is incorrect as negative symptoms of schizophrenia typically involve a decrease or absence of normal functions, which is not clearly demonstrated in this scenario.
The nurse is administering donepezil (Aricept) to a client with stage 1 Alzheimer's disease. Based on this drug's mechanism of action, the nurse will seek evidence of improvement in the client's:
- A. Ability to remember
- B. Ability to tolerate stress
- C. Social behaviors
- D. Delusions and hallucinations
Correct Answer: A
Rationale: The correct answer is A: Ability to remember. Donepezil is a cholinesterase inhibitor that works by increasing levels of acetylcholine in the brain, which helps improve cognitive function, particularly memory. Therefore, the nurse should seek evidence of improvement in the client's ability to remember.
Choice B: Ability to tolerate stress is incorrect because donepezil does not directly impact stress tolerance.
Choice C: Social behaviors is incorrect as donepezil primarily targets memory and cognitive function, not social behaviors.
Choice D: Delusions and hallucinations is incorrect because donepezil does not specifically address these symptoms, which are more commonly associated with psychosis rather than Alzheimer's disease.