Nokea
Select the best comment for a nurse to begin an interview with an elderly patient.
- A. I am a nurse. Are you familiar with what nurses do?
- B. Hello. I am going to ask you some questions to get to know you better.
- C. You look comfortable and ready to participate in an admission interview. Shall we get started?
- D. Hello. My name is_____ and I am a nurse. How you would like to be addressed by staff?
Correct Answer: D
Rationale: The correct answer is D because it establishes the nurse's identity and shows respect by asking the patient's preference for addressing them. This approach sets a positive tone and promotes patient-centered care. Option A is incorrect as it assumes the patient's familiarity with nurses. Option B lacks professionalism and fails to acknowledge the purpose of the interview. Option C assumes the patient's readiness without confirming it directly and may come off as presumptuous.
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Which is a common physical finding in patients with bulimia nervosa?
- A. Low blood pressure and bradycardia.
- B. Hyperactivity and increased energy.
- C. Dental enamel erosion and swollen parotid glands.
- D. Constipation and abdominal bloating.
Correct Answer: C
Rationale: The correct answer is C, dental enamel erosion and swollen parotid glands, in patients with bulimia nervosa. This is due to frequent self-induced vomiting. Enamel erosion is caused by stomach acid exposure during vomiting. Swollen parotid glands result from repeated purging. Choices A, B, and D are incorrect because low blood pressure and bradycardia are more common in anorexia nervosa, hyperactivity and increased energy are not typical in bulimia nervosa, and constipation and abdominal bloating are not specific to this disorder.
A client admitted with delusions, hallucinations, and thought disorder has the admitting diagnosis schizophreniform disorder R/O organic pathology. Based on this information, the nurse can expect that the client will:
- A. Undergo an MRI test
- B. Have psychological testing
- C. Have an immunologic assay performed
- D. Participate in a dexamethasone suppression test
Correct Answer: A
Rationale: Step 1: The client is admitted with symptoms suggestive of a psychotic disorder, specifically schizophreniform disorder.
Step 2: The admitting diagnosis includes ruling out organic pathology, indicating a need to investigate potential physical causes.
Step 3: An MRI test is a non-invasive imaging procedure that can help identify any structural abnormalities in the brain.
Step 4: This test is appropriate in ruling out organic causes of the symptoms presented by the client.
Step 5: Psychological testing (Choice B) is more focused on assessing cognitive and emotional functioning, not ruling out organic pathology.
Step 6: Immunologic assay (Choice C) is used to detect antibodies or antigens in the blood, not typically relevant in this context.
Step 7: Dexamethasone suppression test (Choice D) is used to assess for abnormalities related to cortisol levels in conditions like depression, not specific to ruling out organic pathology in psychotic disorders.
Summary: Choice A is correct because an MRI test is the most relevant
A patient reports, 'My brain is tapped. The government has implanted a device in my head.' What outcome would the nurse identify as being appropriate for the patient to achieve within 1 week of admission?
- A. Taking antipsychotic medication as prescribed without objection
- B. Giving coherent data to support beliefs that the brain is 'tapped'
- C. Interpreting reality correctly by stating no 'brain tap' has been implanted
- D. Reporting feeling less anxious about having the government listening to interior thoughts
Correct Answer: C
Rationale: The correct answer is C because it reflects the goal of promoting reality testing and challenging the patient's delusional beliefs. By helping the patient interpret reality correctly and recognize that the implanted device is not real, the nurse can support the patient in overcoming their delusions and improving their mental health.
Choice A is incorrect as simply taking medication does not address the underlying delusional belief. Choice B is incorrect as it validates and reinforces the patient's delusion, which is not therapeutic. Choice D is incorrect as it does not address the core issue of the patient's delusional belief and may not lead to long-term improvement in mental health.
A family has noted the following behaviors in one of their elderly parents: periodic indecisiveness, forgetfulness, mild transient confusion, occasional misperception, distractibility, and occasional unclear thinking. Where on the continuum of cognitive responses would this patient be?
- A. At point 1
- B. At point 2
- C. At point 3
- D. There is insufficient information to make a determination.
Correct Answer: B
Rationale: The correct answer is B: At point 2. This patient's symptoms indicate mild cognitive impairment, which falls between normal age-related decline (point 1) and dementia (point 3). Mild cognitive impairment involves noticeable cognitive changes but does not significantly interfere with daily functioning. Point 1 is too mild for the symptoms described, and point 3 is too severe as the patient's symptoms are not indicative of full-blown dementia. Therefore, the patient is best placed at point 2 on the continuum of cognitive responses.
Which therapy is shown through evidence to be the most effective for a patient with an eating disorder?
- A. Supportive therapy.
- B. Behavioral therapy.
- C. Cognitive behavioral therapy.
- D. Psychoanalytical group therapy.
Correct Answer: C
Rationale: The correct answer is C: Cognitive behavioral therapy (CBT). CBT is the most effective therapy for eating disorders based on research evidence. It helps patients identify and change negative thoughts and behaviors related to food and body image. CBT also teaches coping skills and strategies to manage triggers. Supportive therapy (choice A) offers emotional support but may not target the underlying issues. Behavioral therapy (choice B) focuses on changing specific behaviors but may not address cognitive patterns. Psychoanalytical group therapy (choice D) delves into past experiences but is not as effective as CBT in treating eating disorders.