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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 nurses 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 patient appears to be experiencing normal grief related to the loss of her family, but because of age and social isolation, the risk for suicide should be determined and has high priority. No defining characteristics exist for the diagnoses of anxiety or spiritual distress. The patients social isolation is important, but the risk for suicide has higher priority.
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Which nursing intervention will assist a client being treated in the Emergency Department for extensive soft tissue injuries to disclose an experience of domestic violence?
- A. Interviewing her in the presence of another professional
- B. Speaking with the client in the absence of her husband
- C. Providing a safe, nonintimidating environment
- D. Allowing the client to initiate the topic of violence
Correct Answer: C
Rationale: Rationale for Correct Answer (C): Providing a safe, nonintimidating environment is crucial to encourage the client to disclose domestic violence. This approach helps establish trust and confidentiality, making the client feel secure to share sensitive information. It creates a conducive setting for open communication without fear of repercussions.
Summary of Incorrect Choices:
A: Interviewing her in the presence of another professional may not ensure privacy and could potentially increase the client's discomfort or fear of being overheard.
B: Speaking with the client in the absence of her husband might not guarantee safety and confidentiality, as the client may still feel threatened or hesitant to reveal the abuse.
D: Allowing the client to initiate the topic of violence puts the burden on the client, who may already be feeling overwhelmed or unable to bring up the sensitive issue without support and encouragement.
A 14-year-old female comes into clinic for a medical certificate once a week for multiple complaints of chest pain and abdominal pain. The complaints are non-specific, and her physical examination is normal. She is quiet with poor eye contact. She states the pain is worse on school days. Her mother is concerned that her daughter is being bullied but won't talk to her. Her mother is also worried that her complaints represent an undiagnosed medical condition. The next best step in management is:
- A. Referral to tertiary hospital to rule out organic cause
- B. HEADSS or other psychosocial screening
- C. Referral for counselling
- D. Reassurance that nothing is wrong
Correct Answer: B
Rationale: HEADSS screening assesses psychosocial factors (e.g., bullying, stress) that may underlie somatic complaints, making it the best next step before referral or reassurance.
The nurse who assesses a patient previously diagnosed as having paranoid personality disorder is most likely to describe the patient as:
- A. superficially charming.
- B. intense and impulsive.
- C. guarded and distant.
- D. friendly and open.
Correct Answer: C
Rationale: The correct answer is C: guarded and distant. This is because individuals with paranoid personality disorder typically exhibit suspiciousness, mistrust, and a reluctance to confide in others. They tend to be hypervigilant and wary of others, leading them to appear guarded and distant.
A: Superficially charming is incorrect because individuals with paranoid personality disorder are more likely to be cautious and suspicious rather than charming.
B: Intense and impulsive is incorrect as this description is more characteristic of individuals with borderline personality disorder, not paranoid personality disorder.
D: Friendly and open is incorrect because individuals with paranoid personality disorder are more likely to be reserved and cautious in their interactions.
In summary, the correct answer is C because individuals with paranoid personality disorder typically exhibit guarded and distant behavior due to their suspicious and mistrustful nature.
A patient receiving risperidone (Risperdal) reports severe muscle stiffness midmorning. During lunch he has difficulty swallowing food and speaking, and when vital signs are taken 30 minutes later, he is noted to be stuporous and diaphoretic, with a temperature of 38.8° C, pulse of 110 beats/min, and blood pressure of 150/90 mm Hg. The nurse should suspect _____ and should _____.
- A. Neuroleptic malignant syndrome"¦place him in a cooling blanket and transfer to ICU
- B. Anticholinergic toxicity"¦check vital signs and prepare to use a cooling blanket stat
- C. Relapse of his psychosis"¦administer PRN antipsychotic drugs and notify his physician
- D. Agranulocytosis"¦hold his antipsychotic and draw blood for a complete blood count
Correct Answer: A
Rationale: The correct answer is A: Neuroleptic malignant syndrome. The patient is exhibiting symptoms consistent with NMS, a rare but serious side effect of antipsychotic medications like risperidone. The severe muscle stiffness, difficulty swallowing, altered mental status, diaphoresis, elevated temperature, and vital sign changes are classic signs of NMS. Treatment includes immediate cooling to lower the body temperature and transfer to the intensive care unit for close monitoring and supportive care.
Choice B: Anticholinergic toxicity does not fit the patient's presentation as there are no specific signs of anticholinergic toxicity such as dry mucous membranes, dilated pupils, or tachycardia.
Choice C: Relapse of psychosis is unlikely to present with the same constellation of symptoms, including altered mental status, fever, and vital sign changes.
Choice D: Agranulocytosis is characterized by a severe drop in white blood cells, leading to increased risk of infection, but it does
Which of the following is an example of a Specific Learning Disability?
- A. Mental Retardation
- B. Dyslexia
- C. ADHD
- D. Autistic spectrum disorders
Correct Answer: B
Rationale: Dyslexia: A persistent, chronic condition in which reading ability lags behind that of non-impaired individuals for the course of most of their lifetime.