Nokea
Male erectile disorder is always the result of psychological factors
- A. TRUE
- B. FALSE
Correct Answer: B
Rationale: Erectile disorder can stem from both psychological (e.g., anxiety) and physical (e.g., vascular) causes.
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An elderly client was well until 12 hours ago, when she reported to her family that during the evening she saw strange faces peering in her windows and in the middle of the night awakened to see a man standing at the foot of her bed. She admits to being very frightened. She is presently pacing and somewhat agitated in the examining room. The client's family reports that the client has recently been to the doctor, who made some medication changes, although they are unsure what the changes were. Which nursing intervention should the nurse implement at the time of this client's admission?
- A. Interact with the client on an adult to child level.
- B. Place the client in a safe, nonstimulating environment.
- C. Ask client why she thinks someone would be trying to frighten her.
- D. Explain to the family that the client will be restrained for her own good.
Correct Answer: B
Rationale: The correct answer is B: Place the client in a safe, nonstimulating environment. This is the most appropriate nursing intervention because the client is experiencing hallucinations and agitation, which could be due to the recent medication changes. Placing the client in a safe, calm environment can help reduce stimulation and provide a sense of security. This intervention addresses the client's immediate needs by ensuring her safety and promoting a sense of comfort.
Incorrect answers:
A: Interact with the client on an adult to child level - This is not appropriate as it does not address the client's current state of distress and could potentially worsen the situation.
C: Ask client why she thinks someone would be trying to frighten her - This is not the priority at this time, as the client is experiencing hallucinations and agitation that need to be managed first.
D: Explain to the family that the client will be restrained for her own good - Restraints should only be used as a last resort and should not be considered
Schizophrenia is usually diagnosed in:
- A. Infancy
- B. Childhood
- C. Early adulthood
- D. Old age
Correct Answer: C
Rationale: Schizophrenia typically emerges in early adulthood (late teens to early 20s), though symptoms may appear earlier or later in rare cases.
A 32-year-old client with an admitting diagnosis of catatonic schizophrenia has been mute and motionless for 2 days. The priority nursing diagnosis is:
- A. Risk for deficient fluid volume
- B. Impaired physical mobility
- C. Impaired social interaction
- D. Ineffective coping
Correct Answer: A
Rationale: The correct answer is A: Risk for deficient fluid volume. The priority nursing diagnosis in this case is to address the client's physical needs to ensure their safety and well-being. The client's mutism and immobility put them at risk for dehydration and malnutrition. By prioritizing the risk for deficient fluid volume, the nurse can address the immediate physiological needs of the client.
Choice B: Impaired physical mobility is incorrect because while the client is motionless, the immediate concern is addressing the risk of dehydration.
Choice C: Impaired social interaction is incorrect as addressing social interaction is not the priority when the client's physical needs are not being met.
Choice D: Ineffective coping is incorrect because the client's presentation is indicative of a more urgent physical need for hydration and nutrition.
What is the priority intervention for a nurse caring for a patient with bulimia nervosa?
- 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: Assist the patient to identify triggers to binge eating. This intervention is crucial for managing bulimia nervosa as it helps address the root cause of the behavior. By identifying triggers, the patient can develop strategies to avoid or cope with them, ultimately reducing the frequency of binge eating episodes. Choices B, C, and D are incorrect because providing consequences for weight loss may reinforce unhealthy behaviors, assessing for impulsive eating is not addressing the underlying triggers, and exploring needs for health teaching is not as immediate and targeted as identifying triggers for binge eating.
An adult diagnosed with a serious mental illness says, I do not need help with money management. I have excellent ideas about investments. This patient usually does not have money to buy groceries by the middle of the month. The nurse assesses the patient as demonstrating:
- A. rationalization.
- B. identification.
- C. anosognosia.
- D. projection.
Correct Answer: C
Rationale: The patient shows anosognosia (C), an inability to recognize deficits due to illness, believing in their financial acumen despite evidence. This isn't rationalization (A), identification (B), or projection (D).