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Police bring a patient to the mental health unit. The patient was directing traffic and shouting rhymes on a busy city street. The patient's spouse reports that the patient has not slept or eaten for 3 days. Which assessment findings have priority concern for this patient's plan of care?
- A. Pressured speech and grandiosity
- B. Hyperactivity; not eating and sleeping
- C. Poor concentration and decision making
- D. Insulting
Correct Answer: B
Rationale: The correct answer is B. Hyperactivity, not eating, and not sleeping are priority concerns as they indicate potential mania or hypomania, which can be dangerous and require immediate intervention. Not eating and sleeping for days can lead to physical and mental health complications. Pressured speech and grandiosity (Choice A) are symptoms of mania but not as urgent as lack of eating and sleeping. Poor concentration and decision making (Choice C) are also symptoms of mania, but not as immediately concerning as the lack of eating and sleeping. Insulting behavior (Choice D) is not a priority concern for immediate intervention in this scenario.
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The nursing diagnosis most likely to be used for a person who has a diagnosis of schizophrenia, paranoid type, is:
- A. social isolation related to impaired ability to trust.
- B. impaired mobility related to fear of losing control of hostile impulses.
- C. fear of being alone related to lack of confidence in significant others.
- D. impaired memory related to poor information processing associated with brain deficits.
Correct Answer: A
Rationale: Step-by-step rationale for choice A:
1. Schizophrenia, paranoid type, involves mistrust and suspicion.
2. Impaired ability to trust can lead to social isolation.
3. "Impaired ability to trust" directly relates to social isolation.
4. Therefore, "social isolation related to impaired ability to trust" is the most likely nursing diagnosis.
Summary of other choices:
- B: Not directly related to mistrust in paranoid schizophrenia.
- C: Lack of confidence in significant others is not a defining characteristic of paranoid schizophrenia.
- D: Impaired memory is not a primary feature of paranoid schizophrenia.
A client has been diagnosed with Alzheimer's disease, stage 1. The nurse would expect to help the family plan measures to assist the client with:
- A. Recent memory loss
- B. Catastrophic reactions
- C. Progressive gait disturbances
- D. Perseveration
Correct Answer: A
Rationale: The correct answer is A: Recent memory loss. In stage 1 of Alzheimer's disease, the primary symptom is mild memory loss, particularly with recent events and information. The nurse would help the family plan measures to assist the client by implementing strategies to support memory, such as setting reminders, organizing daily routines, and using memory aids. Choice B, catastrophic reactions, is more commonly associated with later stages of the disease. Choice C, progressive gait disturbances, is not a typical symptom of stage 1 Alzheimer's. Choice D, perseveration, involves the repetition of a particular response or behavior and is not a primary concern in stage 1 Alzheimer's disease.
A young, newly married adult says, 'My spouse never lets me out of sight. I'm not allowed to do anything on my own, and I'm constantly accused of cheating.' Which nursing communication is most therapeutic for this patient?
- A. Have you discussed the behavior with your spouse?'
- B. How does your spouse's behavior make you feel?'
- C. Are there other examples of controlling behaviors on your spouse's part?'
- D. Do you feel that your spouse has anything to be upset or suspicious about?'
Correct Answer: B
Rationale: The correct answer is B: "How does your spouse's behavior make you feel?" This question focuses on the patient's emotions, allowing them to express their feelings and validating their experiences. It shows empathy and encourages the patient to explore and understand their own emotional responses to the situation.
Choice A focuses on addressing the behavior directly without acknowledging the patient's emotions. Choice C asks for more examples of controlling behavior, which may feel judgmental. Choice D suggests that the spouse's behavior is justified, which can further invalidate the patient's feelings. Overall, choice B is the most therapeutic as it promotes emotional exploration and support.
A patient remanded by the court after his wife had him jailed for battery told the judge how sorry he was and suggested he needed psychiatric help. His history reveals acting-out behaviors as an adolescent and several adult arrests. The nurse interviews him about his relationship with his wife. Which statement by the patient is most consistent with a diagnosis of antisocial personality disorder?
- A. I've done some stupid things in my life, but I've learned a lesson.'
- B. I'm feeling terrible about the way my behavior has hurt my family.'
- C. I have a quick temper, but I can usually keep it under control.'
- D. I hit her because she nags at me. She deserves it when I beat her up.'
Correct Answer: D
Rationale: The correct answer is D. This statement reflects a lack of remorse, empathy, and justification for violent behavior, which are key characteristics of antisocial personality disorder. The patient blames his wife for his violent actions and shows a sense of entitlement.
A: This statement shows acknowledgment of mistakes and a willingness to learn from them, which is not consistent with antisocial personality disorder.
B: Expressing feeling terrible about hurting family members demonstrates some level of empathy and remorse, which is not typical of individuals with antisocial personality disorder.
C: Acknowledging a quick temper but being able to control it does not align with the impulsivity and lack of control often seen in individuals with antisocial personality disorder.
A psychiatric technician mentions to the nurse, 'All these clients with Axis II problems! It makes me wonder how so many mothers could have been such poor parents and messed up their kids so badly!' The response by the nurse that helps put the development of personality disorders into perspective is:
- A. Parenting is the responsibility of fathers, too, so don't blame only mothers.'
- B. Personality disorder is often related to sexual abuse that occurs without parental knowledge.'
- C. There is some evidence to suggest a biologic component to personality disorders.'
- D. Peer interactions may be more important in child development than parental involvement.'
Correct Answer: C
Rationale: Step-by-step rationale for why choice C is correct:
1. Personality disorders are complex conditions influenced by a combination of genetic, environmental, and biological factors.
2. Research has shown evidence suggesting a biological component in the development of personality disorders.
3. Understanding the biological component helps to destigmatize and provide a more comprehensive view of personality disorders.
4. This response helps the psychiatric technician understand that blaming parents solely is not accurate and that multiple factors contribute to the development of personality disorders.
Summary:
Choice C is correct because it highlights the importance of considering biological factors in the development of personality disorders, providing a more holistic perspective. Choices A, B, and D are incorrect as they do not address the multifactorial nature of personality disorders.