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People who experience psychotic disorders lose:
- A. The will to continue
- B. Contact with reality
- C. The ability to comply with treatment
- D. Contact with intellectual functions
Correct Answer: B
Rationale: Certainly! The correct answer is B: People who experience psychotic disorders lose contact with reality. Psychotic disorders involve a disconnection from reality, leading to hallucinations, delusions, and impaired thinking. This loss of contact with reality is a hallmark of psychotic disorders.
As for the other choices:
A: The will to continue - While individuals with psychotic disorders may struggle with motivation, this is not the primary feature of psychotic disorders.
C: The ability to comply with treatment - While compliance with treatment may be challenging, it is not the core aspect of psychotic disorders.
D: Contact with intellectual functions - While psychotic disorders can impact cognitive abilities, the defining characteristic is the loss of contact with reality rather than intellectual functions.
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A 72-year-old client with dementia, who resides in a long-term care facility, frequently goes to her room and cries because she misses her children. This client could benefit most from which intervention?
- A. Life review
- B. Doll therapy
- C. Comfort touch
- D. Audio presence therapy
Correct Answer: D
Rationale: The correct answer is D, Audio presence therapy. This intervention involves playing recordings of loved ones' voices to provide comfort and emotional support. For a client with dementia missing her children, hearing their voices can help reduce feelings of loneliness and provide a sense of connection. Life review (A) may not directly address the client's current emotional needs. Doll therapy (B) and comfort touch (C) may provide some comfort but may not be as effective as directly hearing the voices of her children through audio presence therapy (D).
A client who has been diagnosed as having paranoid schizophrenia is highly suspicious and delusional. He hears voices telling him terrorists are plotting to assassinate him. He refuses to eat, saying the food is poisoned. The nursing action that best addresses his needs is to:
- A. Explain that others eat the food and are not harmed
- B. Allow client to select food from vending machines
- C. Assist client with personal hygiene and grooming
- D. Not allow client to verbalize delusional thoughts
Correct Answer: B
Rationale: The correct answer is B: Allow client to select food from vending machines. This option respects the client's autonomy and addresses his delusion about the food being poisoned. By allowing the client to choose food from vending machines, it acknowledges his concerns and promotes a sense of control over his environment. This approach can help build trust and rapport with the client, as forcing him to eat regular hospital food might exacerbate his paranoia and resistance.
A: Explaining that others eat the food and are not harmed may not be effective as it disregards the client's beliefs and could further alienate him.
C: Assisting with personal hygiene and grooming is important but does not directly address the client's primary concern of refusing to eat due to delusional beliefs.
D: Not allowing the client to verbalize delusional thoughts is counterproductive as it suppresses communication and does not address the underlying issue of the client's fear of being poisoned.
An individual accompanied by a sibling was brought by ambulance to the emergency room with suspected impaired cognitive function. The patient's aggressive behavior and attempts to get out of bed present a safety issue. The nurse should first consider:
- A. applying four-point restraints.
- B. using a calm tone to orient the patient.
- C. leaving the patient alone with the sibling.
- D. calling for security guards to hold the patient down.
Correct Answer: B
Rationale: The correct answer is B: using a calm tone to orient the patient. This is the most appropriate initial intervention because it aims to address the patient's aggressive behavior by providing reassurance and attempting to reorient them to their surroundings. Using a calm tone can help de-escalate the situation and improve communication with the patient. Applying four-point restraints (choice A) should be avoided as it is a restrictive measure that should only be used as a last resort to ensure patient safety. Leaving the patient alone with the sibling (choice C) may exacerbate the safety issue, as the sibling may not be equipped to manage the situation. Calling for security guards to hold the patient down (choice D) is a forceful approach that should be avoided until all other options have been exhausted.
A nursing diagnosis for a patient with bulimia nervosa is Ineffective coping related to feelings of loneliness and isolation, as evidenced by use of overeating and self-induced vomiting to comfort self. Select the best outcome related to this diagnosis. Within 2 weeks, the patient will:
- A. appropriately express angry feelings.
- B. verbalize two positive things about self.
- C. verbalize the importance of eating a balanced diet.
- D. identify two alternative methods of coping with loneliness and isolation.
Correct Answer: D
Rationale: The correct answer is D because it directly addresses the nursing diagnosis of ineffective coping related to feelings of loneliness and isolation. By identifying two alternative methods of coping, the patient can develop healthier strategies to manage these emotions instead of resorting to overeating and vomiting. This outcome promotes long-term behavioral change and helps the patient build resilience.
Choice A is incorrect because expressing angry feelings may not necessarily address the underlying issues of loneliness and isolation. Choice B is incorrect as verbalizing positive things about oneself may be beneficial but does not directly address coping mechanisms for loneliness and isolation. Choice C is also incorrect because understanding the importance of a balanced diet does not directly address coping strategies for managing emotions like loneliness and isolation.
The patient tells his primary nurse 'I get into trouble because I have hair-trigger responses. I shoot from the hip. Lots of times that gets me into a mess.' Which response would be most therapeutic?
- A. Let's look at ways to help you slow it down and think before acting.'
- B. It might help to explore how you came to be that way"“any ideas?'
- C. I'll bet you have some interesting stories to share about overreacting.'
- D. It's good that you're showing readiness and motivation to change.'
Correct Answer: A
Rationale: The correct answer is A because it demonstrates empathy and offers a therapeutic approach to help the patient manage their hair-trigger responses. By suggesting ways to slow down and think before acting, the nurse is providing practical strategies for the patient to work on self-regulation and impulse control. This response shows active listening and a commitment to supporting the patient in developing coping mechanisms.
Option B is incorrect as it focuses on exploring the root cause rather than offering immediate support. Option C is incorrect as it may encourage dwelling on past mistakes rather than focusing on problem-solving. Option D is incorrect as it praises the patient without addressing the need for behavior change.