Nokea
Stuttering is a disturbance in the normal fluency and time patterning of speech that is inappropriate for the individual's age. It involves which of the following?
- A. Frequent repetitions or prolongations of sounds
- B. Pauses within words
- C. Filled or unfilled pauses in speech
- D. All of the above
Correct Answer: D
Rationale: Stuttering: A disturbance in the normal fluency and time patterning of speech that includes frequent repetitions, prolongations, and pauses.
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An adult patient tells the case manager, 'I dont have bipolar disorder anymore, so I dont need medicine. After I was in the hospital last year, you helped me get an apartment and disability checks. Now Im bored and dont have any friends.' Where should the nurse refer the patient? Select one tha does not apply.
- A. Psychoeducational classes
- B. Vocational rehabilitation
- C. Social skills training
- D. A homeless shelter
Correct Answer: D
Rationale: The patient does not understand the illness and need for adherence to the medication regimen. Psychoeducation for the patient (and family) can address this lack of knowledge. The patient, who considers himself friendless, could also profit from social skills training to improve the quality of interpersonal relationships. Many patients with serious mental illness have such poor communication skills that others are uncomfortable interacting with them. Interactional skills can be effectively taught by breaking the skill down into smaller verbal and nonverbal components. Work gives meaning and purpose to life, so vocational rehabilitation can assist with this aspect of care. The nurse case manager will function in the role of crisis stabilizer, so no related referral is needed. The patient presently has a home and does not require a homeless shelter.
A nurse can anticipate anticholinergic side effects are likely when a patient takes:
- A. Lithium (Lithobid).
- B. Buspirone (BuSpar).
- C. Risperidone (Risperdal).
- D. Fluphenazine (Prolixin)
Correct Answer: D
Rationale: The correct answer is D, Fluphenazine (Prolixin), as it is a typical antipsychotic medication known to have strong anticholinergic effects. Anticholinergic side effects include dry mouth, constipation, blurred vision, and urinary retention. Fluphenazine blocks the action of acetylcholine in the brain, leading to these side effects. Choices A, B, and C are incorrect as they do not have significant anticholinergic effects compared to Fluphenazine. Lithium is a mood stabilizer, Buspirone is an anxiolytic, and Risperidone is an atypical antipsychotic, none of which are known for causing prominent anticholinergic side effects.
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
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.
An adult experienced a myocardial infarction six months ago. At a follow-up visit, this adult says, 'I haven't had much interest in sex since my heart attack. I finished my rehabilitation program, but having sex strains my heart. I don't know if my heart is strong enough.' Which nursing diagnosis applies?
- A. Deficient knowledge related to faulty perception of health status
- B. Disturbed self-concept related to required lifestyle changes
- C. Disturbed body image related to treatment side effects
- D. Sexual dysfunction related to self-esteem disturbance
Correct Answer: A
Rationale: The correct answer is A: Deficient knowledge related to faulty perception of health status. The patient's statement indicates a lack of understanding about their health status and the impact of their myocardial infarction on their sexual activity. The patient is attributing their decreased interest in sex to a fear of straining their heart, indicating a faulty perception of their health status. This nursing diagnosis addresses the patient's need for education and clarification about their condition to alleviate their concerns and improve their confidence in engaging in sexual activity safely.
Choices B, C, and D are incorrect because they do not directly address the patient's lack of knowledge and faulty perception about their health status. Disturbed self-concept (B) relates more to how the patient perceives themselves due to lifestyle changes, while disturbed body image (C) pertains to physical appearance changes. Sexual dysfunction (D) is related to difficulties in sexual function, which is not the primary issue in this scenario.