Nokea
In the OB follow-up clinic, your patient, who is 4 weeks post-delivery, tells you she is sleeping for long hours, wants to avoid taking care of the baby, and wishes she had never had the baby. What would be your first response?
- A. Its normal to feel overwhelmed at first.
- B. Tell me more about these feelings.
- C. Report her to Child Protective Services.
- D. Ill call your husband right away to get you back home to rest.
Correct Answer: B
Rationale: The open-ended question (B) will give you more information and be less judgmental to this patient. This behavior is not normal at 4 weeks post-delivery and more rest is probably not adequate treatment. You would like a lot more information before reporting this as neglect.
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The nurse has been working with a patient diagnosed with schizophrenia who experiences auditory hallucinations. The patient relates, 'When I first heard the voices they said nice things about me. Lately, they've changed and they say bad things.' What information has the least impact on therapeutic patient care at this point in the hospitalization?
- A. Do you trust me to help you with the voices?'
- B. Are the voices commanding you to do something?'
- C. How often during 24 hours do you hear the voices?'
- D. Do you hear the voices if you're busy in noisy environment?'
Correct Answer: A
Rationale: Rationale for Correct Answer (A): Asking the patient if they trust the nurse to help with the voices is the least impactful at this point because establishing trust should have already been a priority earlier in the hospitalization. The focus now should be on assessing the nature and frequency of the auditory hallucinations to guide further treatment and intervention.
Summary of Incorrect Choices:
B: This question is important to assess if the voices are commanding potentially harmful actions.
C: Understanding the frequency of the voices is crucial in evaluating the severity of the symptoms.
D: Inquiring about hearing voices in different environments helps assess the impact of external factors on the hallucinations.
In DSM-IV-TR intellectual disabilities are divided into a number of degrees of severity, depending primarily on the range of IQ score provided by the sufferer. One of these is Moderate Mental Retardation, represented by an IQ score between:
- A. 60-65 - to 70-75
- B. 35-40 to 50-55
- C. 80-85 to 90-95
- D. 20-25 to 30-35
Correct Answer: B
Rationale: Moderate Mental Retardation: Defined by DSM-IV-TR as an IQ score between 35-40 to 50-55.
The wife of a client newly diagnosed with paranoid schizophrenia asks the nurse, 'My husband was well adjusted until a month ago, and then, after a lot of work stress, he got sick. What can I expect? Will he be this sick for the rest of his life?' What information can the nurse provide about prognosis?
- A. This disorder responds well to treatment and, with follow-up, may not recur.'
- B. All types of schizophrenia are chronic relapsing disorders.'
- C. Outcomes are poor related to client prehospital disorganization.'
- D. The usual outcome is that only partial remission is achieved.'
Correct Answer: A
Rationale: The correct answer is A: "This disorder responds well to treatment and, with follow-up, may not recur."
Rationale:
1. Paranoid schizophrenia typically responds well to treatment, especially with early intervention.
2. With proper medication and therapy, individuals with paranoid schizophrenia can experience significant improvement and lead fulfilling lives.
3. Follow-up care and support are crucial in maintaining stability and preventing relapses.
Summary of why other choices are incorrect:
B: All types of schizophrenia are chronic relapsing disorders - This is not accurate as outcomes can vary depending on the subtype of schizophrenia.
C: Outcomes are poor related to client prehospital disorganization - This statement is too general and does not specifically address the prognosis of paranoid schizophrenia.
D: The usual outcome is that only partial remission is achieved - This is not always the case, as many individuals with paranoid schizophrenia can achieve full remission with appropriate treatment.
A woman tells the nurse, 'My partner is frustrated with me. I don't have any natural lubrication when we have sex.' What type of sexual disorder is evident?
- A. Genito-pelvic pain/penetration disorder
- B. Female sexual interest/arousal disorder
- C. Hypoactive sexual desire disorder
- D. Female orgasmic disorder
Correct Answer: B
Rationale: The correct answer is B: Female sexual interest/arousal disorder. The woman's complaint of lack of natural lubrication during sex indicates a difficulty in arousal, which falls under this disorder category. This is because arousal difficulties can lead to inadequate lubrication, impacting sexual satisfaction. Genito-pelvic pain/penetration disorder (A) involves pain during intercourse, not lack of lubrication. Hypoactive sexual desire disorder (C) refers to low libido, not lubrication issues. Female orgasmic disorder (D) pertains to difficulties reaching orgasm, not lubrication problems.
What is the priority nursing intervention when caring for a patient with bulimia nervosa who has a history of purging?
- A. Provide emotional support and assist with stress management.
- B. Monitor vital signs and electrolyte levels closely.
- C. Encourage the patient to exercise regularly to prevent weight gain.
- D. Help the patient identify triggers for binge eating and purging behaviors.
Correct Answer: B
Rationale: The correct answer is B because monitoring vital signs and electrolyte levels closely is crucial in managing a patient with bulimia nervosa who has a history of purging. Purging can lead to electrolyte imbalances and dehydration, which can have serious consequences such as cardiac arrhythmias and electrolyte disturbances. By closely monitoring vital signs and electrolyte levels, nurses can quickly identify and intervene in case of any abnormalities, preventing potential life-threatening complications.
Choice A is incorrect because emotional support and stress management are important but not the priority when dealing with physical complications from purging. Choice C is incorrect because encouraging exercise may exacerbate the patient's unhealthy behaviors and should be approached cautiously. Choice D is incorrect because identifying triggers is important but not as immediate as monitoring vital signs and electrolyte levels in this situation.