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In a sad voice, an elderly patient tells the nurse of the recent deaths of a spouse and close friend. The patient has no other family and only a few acquaintances in the community. The nurse's priority is to determine whether which nursing diagnosis applies to this patient?
- A. Risk for suicide related to recent deaths of significant others
- B. Anxiety related to sudden and abrupt lifestyle changes
- C. Social isolation related to loss of existing family
- D. Spiritual distress related to anger with God
Correct Answer: A
Rationale: The correct answer is A: Risk for suicide related to recent deaths of significant others. This is the priority because the patient's recent losses put them at high risk for suicide. The nurse must assess the patient's risk level and provide appropriate interventions to prevent harm. Choices B, C, and D are incorrect because anxiety and social isolation are secondary concerns compared to the immediate risk of suicide. Spiritual distress, while important, does not take precedence over the patient's safety.
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The nurse notes that a male client, who is taking an antipsychotic medication, is constantly moving from chair to chair during a group activity, and he complains that he feels 'nervous and jittery inside.' The nurse is aware that this client most likely is experiencing:
- A. Akinesia
- B. Dystonia
- C. Dyskinesia
- D. Akathisia
Correct Answer: D
Rationale: The correct answer is D: Akathisia. Akathisia is a common side effect of antipsychotic medications characterized by restlessness, inability to sit still, and a feeling of inner restlessness or jitteriness. In this case, the client's constant movement and feeling of nervousness align with the symptoms of akathisia.
A: Akinesia is the opposite of what the client is experiencing, characterized by a lack of movement or muscle weakness.
B: Dystonia involves involuntary muscle contractions and abnormal postures, not constant movement.
C: Dyskinesia refers to abnormal, involuntary movements of the face, trunk, and limbs, which are not described in the scenario.
Which of the following statements about attention deficit hyperactivity disorder (ADHD) are true? (Select one tha does not apply)
- A. ADHD is more common in boys than in girls
- B. Children with ADHD tend to be of below-average intelligence
- C. Even though we think of ADHD as a disorder in children, adults can also have it
- D. Children with ADHD are often treated with the use of stimulants
Correct Answer: B
Rationale: Children with ADHD tend to be of above normal intelligence but often dont function at those levels. The causes of ADHD are more associated with brain dysfunction and genetic factors. Correct statements are: A (more common in boys), D (treated with stimulants), E (benefit from behavior modification), F (can persist into adulthood).
Which complication should a nurse monitor for when treating a patient with bulimia nervosa who is experiencing frequent vomiting?
- A. Hypokalemia and dental enamel erosion.
- B. Hyperkalemia and elevated blood pressure.
- C. Severe dehydration and low blood sugar.
- D. Hypercalcemia and weight gain.
Correct Answer: A
Rationale: The correct answer is A: Hypokalemia and dental enamel erosion.
1. Bulimia nervosa involves frequent vomiting, leading to loss of potassium (hypokalemia) due to electrolyte imbalance.
2. Vomiting also damages tooth enamel, causing dental erosion.
3. Hyperkalemia and elevated blood pressure (choice B) are not typically associated with bulimia.
4. Severe dehydration and low blood sugar (choice C) are possible but not the primary concerns.
5. Hypercalcemia and weight gain (choice D) are not common complications of bulimia.
The drug of choice for treating Tourette syndrome?
- A. Fluoxetine
- B. Fluvoxamine
- C. Haloperidol
- D. Paroxetine
Correct Answer: C
Rationale: Haloperidol is a typical antipsychotic commonly used to reduce tics in Tourette syndrome by modulating dopamine activity.
Which behaviors would indicate the need for further assessment to consider avoidant personality disorder?
- A. Withholding of feelings and low self-esteem
- B. Insistence on others conforming to own methods
- C. Engaging in impulsive acts like unsafe sex
- D. Initial charm dissolving into coldness and blaming others
Correct Answer: A
Rationale: Step 1: Withholding of feelings is a key feature of avoidant personality disorder, indicating difficulty in expressing emotions.
Step 2: Low self-esteem is also characteristic, as individuals with this disorder often feel inadequate and inferior.
Step 3: Insistence on others conforming to own methods (B) is more indicative of narcissistic personality disorder.
Step 4: Engaging in impulsive acts like unsafe sex (C) is more aligned with borderline personality disorder.
Step 5: Initial charm dissolving into coldness and blaming others (D) is a trait of antisocial personality disorder.