Nokea
False beliefs that are held even when the facts contradict them are called
- A. fantasies
- B. hallucinations
- C. illusions
- D. delusions
Correct Answer: D
Rationale: Delusions are fixed false beliefs resistant to contradictory evidence, unlike hallucinations (perceptions).
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When a patient diagnosed with paranoid schizophrenia was discharged from the unit 6 months ago, the plan was for him to take chlorpromazine (Thorazine), a conventional (first generation) antipsychotic medication, 300 mg po daily. He tells the nurse he stopped taking his pills after a few months because they made him feel like a 'zombie.' What other common side effects should the nurse determine if the patient experienced?
- A. Sweating, nausea, and weight gain
- B. Sedation, tremor, and muscle stiffness
- C. Headache, watery eyes, and runny nose
- D. Mild fever, sore throat, and skin rash
Correct Answer: B
Rationale: The correct answer is B: Sedation, tremor, and muscle stiffness. These side effects are commonly associated with conventional antipsychotic medications like chlorpromazine. Sedation is a common side effect that can make the patient feel drowsy or sluggish. Tremors are involuntary muscle movements that can affect the hands, arms, or legs. Muscle stiffness can cause rigidity and difficulty moving smoothly. These side effects are known to impact the quality of life and may contribute to the patient feeling like a 'zombie.'
Choices A, C, and D are incorrect because they do not align with the common side effects of conventional antipsychotic medications. Sweating, nausea, and weight gain (Choice A) are not typical side effects of chlorpromazine. Headache, watery eyes, and runny nose (Choice C) are more commonly associated with allergies or cold symptoms rather than antipsychotic medications. Mild fever, sore throat, and skin rash (Choice D)
Which aspect of assessment has priority when a nurse interviews a rape victim?
- A. Coping mechanisms the patient is using
- B. The patient's previous sexual experiences
- C. Adequacy of the patient's interpersonal relationships
- D. Whether the patient has ever had a sexually transmitted disease
Correct Answer: A
Rationale: The correct answer is A: Coping mechanisms the patient is using. This aspect has priority because it helps the nurse assess the immediate emotional and psychological impact of the trauma on the victim. Understanding coping mechanisms can guide the nurse in providing appropriate support and interventions. Choice B is incorrect as past sexual experiences are not as pertinent during the immediate assessment of a rape victim. Choice C is incorrect as assessing interpersonal relationships may not be a priority during the initial interview. Choice D is incorrect as the presence of a sexually transmitted disease is not the primary concern when assessing a rape victim.
The daughter of an 84-year-old client with dementia tearfully tells the nurse that she doesn't know what's wrong with her mother, who has begun accusing the family of stealing her lingerie and holding her prisoner. The nurse assesses the client's stage of Alzheimer's disease as stage:
- A. 1
- B. 2
- C. 3
- D. 4
Correct Answer: B
Rationale: The correct answer is B (stage 2) because the client is exhibiting symptoms of moderate Alzheimer's disease, such as paranoia and delusions. In stage 2, cognitive decline becomes more noticeable, leading to memory loss, confusion, and behavioral changes. The client's accusations and false beliefs indicate a decline in reality orientation, which is characteristic of stage 2. Choices A, C, and D are incorrect because stage 1 is characterized by mild cognitive decline, stage 3 by severe cognitive decline, and stage 4 by very severe cognitive decline.
After taking an antidepressant for about a week, a patient reports constipation and blurred vision, with no improvement in mood. The psychiatric-mental health nurse informs the patient,:
- A. It takes approximately two to four weeks for depression to lessen, and side effects usually diminish over time'
- B. Stop the medication immediately and contact your primary care physician'
- C. You should contact your doctor. The doctor may need to change your medication'
- D. You should schedule an appointment with your ophthalmologist'
Correct Answer: A
Rationale: Antidepressants require 2-4 weeks for therapeutic effect, and early side effects often subside, making this the most reassuring response.
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.