Nokea
In some countries, it is normal to defecate or urinate in public. This makes it clear that judgments of the normality of behavior are
- A. culturally relative
- B. statistical
- C. a matter of subjective discomfort
- D. related to conformity
Correct Answer: A
Rationale: Normality varies by culture, as behaviors acceptable in one society may be abnormal in another.
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Which statements most clearly indicate the speaker views mental illness with stigma? Select one tha does not apply.
- A. We are all a little bit crazy.'
- B. If people with mental illness would go to church, their problems would be solved.'
- C. Many mental illnesses are genetically transmitted. Its no ones fault that the illness occurs.'
- D. People with mental illness are lazy. They get government disability checks instead of working.'
Correct Answer: C
Rationale: Stigma is represented by judgmental remarks that discount the reality and validity of mental illness. It is evidenced in stereotypical statements, by oversimplification, and by multiple other messages of guilt or shame.
A 28-year-old female client was admitted 3 days ago after she ran nude through the streets shouting that she was the 'Queen of Hearts.' Since admission, the client remains delusional, shouts obscenities, and demonstrates loosely associated thoughts. Based on these data, the nurse should develop a nursing diagnosis of:
- A. Risk for violence
- B. Defensive coping
- C. Disturbed thought processes
- D. Impaired memory
Correct Answer: C
Rationale: The correct answer is C: Disturbed thought processes. The client's behavior of being delusional, shouting obscenities, and demonstrating loosely associated thoughts indicates a disturbance in thought processes. This nursing diagnosis focuses on the client's cognitive functioning and perception of reality.
A: Risk for violence is not the most appropriate diagnosis in this case as there is no direct evidence of the client being a risk to herself or others.
B: Defensive coping does not address the client's specific symptoms of delusions and disorganized thinking.
D: Impaired memory is not the most appropriate diagnosis as the client's symptoms are more indicative of a broader disturbance in thought processes rather than just memory deficits.
Therefore, choice C is the most suitable nursing diagnosis based on the client's presentation of delusional behavior and disorganized thoughts.
An individual brought by ambulance to the emergency room is accompanied by a roommate. The patient fights against the restraints and shouts incoherently. The roommate reports that the patient was weak and confused on awakening this morning and about 3 hours ago began "rambling and talking crazy."Â A nurse notes that the patient's skin is flushed and dry. The priority nursing action is to:
- A. take the patient's vital signs.
- B. start intravenous fluids.
- C. administer a sedative.
- D. perform a mental status examination.
Correct Answer: A
Rationale: The correct answer is A: take the patient's vital signs. This is the priority action because the patient is exhibiting signs of potential medical emergency, such as altered mental status, flushed and dry skin, and confusion. Vital signs can provide crucial information about the patient's condition and help determine the urgency of the situation. Starting intravenous fluids (B) may be necessary but should be based on the assessment of vital signs first. Administering a sedative (C) is not appropriate without knowing the underlying cause of the symptoms. Performing a mental status examination (D) is important but not the priority in this situation where the patient's physical condition needs immediate attention.
Police bring a 63-year-old woman to the emergency room, reporting that her behavior is disorganized and disruptive, that her speech makes little sense, and that she does not seem able to take care of herself. The woman has had elective surgeries at the hospital previously and was seen in the ER last week after a fall; records show no history of similar symptoms or mental illness. The ER physician speaks with the patient but does not examine her medically, diagnoses her with schizophrenia, and orders admission to the inpatient psychiatric unit. Which response by the nurse would be most appropriate?
- A. Ask another physician with more of an interest in psychiatry to also take a look at this patient, explaining that you just want to be as thorough as possible.
- B. Suggest that a psychiatric consult be requested before admitting the patient to a psychiatric unit, to validate the diagnosis and speed the initiation of medication.
- C. Remind the physician that schizophrenia usually develops earlier in life, that such presentations may be caused by medical problems, and suggest a medical work-up.
- D. Note that the patient's blood pressure and respirations were elevated when she arrived, and suggest that they be evaluated before admitting the patient to the psychiatric unit.
Correct Answer: C
Rationale: The correct answer is C because it demonstrates critical thinking and patient advocacy. By reminding the physician that schizophrenia typically develops earlier in life and suggesting a medical work-up, the nurse is advocating for a comprehensive approach to ruling out potential medical causes for the patient's symptoms before jumping to a psychiatric diagnosis. This approach aligns with best practices in patient care and ensures that all possible underlying causes are considered and addressed appropriately.
Choice A is incorrect because it does not address the need for a medical work-up to rule out physical causes of the symptoms. Choice B is incorrect as it focuses on validating the diagnosis and initiating medication rather than investigating potential medical issues. Choice D is incorrect as it only addresses the patient's vital signs, overlooking the need for a thorough medical evaluation.
A 75-year-old male client is brought to the clinic by his son. The son states, 'Ever since Mom died, Dad hasn't been the same. At first he just seemed sad, but now he seems to get mixed up about everything.' The nurse is aware that based on the client's history, the source of confusion is most likely:
- A. Dementia
- B. Depression from the loss of his wife
- C. Hypoxia of the brain
- D. Delirium from medications
Correct Answer: B
Rationale: Correct Answer: B - Depression from the loss of his wife
Rationale: Given the client's recent loss of his wife and subsequent changes in behavior, the most likely cause of his confusion is depression. Depression can manifest as cognitive impairment in older adults, leading to symptoms such as confusion and memory problems. Additionally, grief and loss can exacerbate depressive symptoms in elderly individuals, further contributing to cognitive difficulties.
Summary of other choices:
A: Dementia - Dementia typically presents with gradual cognitive decline over time, not a sudden onset following a specific event like the loss of a loved one.
C: Hypoxia of the brain - Hypoxia would likely present with more acute symptoms and physical signs, such as shortness of breath or cyanosis.
D: Delirium from medications - Delirium is characterized by acute onset and fluctuating course, often related to medication changes or other medical conditions, rather than an emotional trigger like grief.