The chief distinguishing feature of psychotic disorders is
- A. confusion of fantasy and reality
- B. antisocial conduct
- C. overwhelming anxiety
- D. obsessive behavior
Correct Answer: A
Rationale: Psychotic disorders are characterized by a loss of reality testing, such as hallucinations and delusions, distinguishing them from other conditions.
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A client with catatonic schizophrenia has been posturing, standing with his left arm upraised and his right foot off the floor. For the most part, he ignores attempts at nursing intervention but will occasionally walk, sit, or lie down for a few minutes. The client eats standing up if the nurse brings a tray to the room. The priority nursing order would be to:
- A. Insist that client sit or lie down for 30 minutes hourly
- B. Assess for lower extremity edema bid
- C. Provide high-calorie drinks hourly
- D. Take client to activities therapy once daily
Correct Answer: B
Rationale: The correct answer is B. Assess for lower extremity edema bid.
Rationale:
1. Priority is to assess for lower extremity edema as the client is standing for extended periods, which can lead to edema.
2. Edema assessment is crucial for preventing complications like blood clots or skin breakdown.
3. Insisting on sitting or lying down may aggravate the client and worsen the situation.
4. Providing high-calorie drinks or activities therapy are not the immediate priority in this case.
In summary, assessing for lower extremity edema is crucial due to the client's prolonged standing, which can lead to potential health risks, making it the priority nursing order.
The nurse is interviewing a client who presents with a dislocated shoulder. She demonstrates signs of anxiety and poor eye contact and turns to her partner for answers, allowing him to answer for her. Bruises on her breast and upper arm are visible. The nurse asks the partner to go to the admitting office to give insurance information. While the partner is out of the room, which question is most important to ask?
- A. Have you been with your partner long?'
- B. Have you ever been physically or emotionally hurt by someone?'
- C. Are you an abused woman?'
- D. Shall I notify the police that you would like to press charges?'
Correct Answer: B
Rationale: The correct answer is B: "Have you ever been physically or emotionally hurt by someone?" This question is important as it directly addresses the potential abuse the client may be experiencing. It allows the nurse to assess for any history of abuse, which could be contributing to the client's anxiety and behavior. It also opens up an opportunity for the client to disclose any abuse they may be facing.
Choice A is incorrect because the length of the relationship with the partner is not as crucial as addressing the potential abuse. Choice C is also incorrect because it is too direct and may not encourage the client to open up about their experiences. Choice D is incorrect as it assumes the client wants to press charges without first assessing the situation and the client's wishes.
A couple in counseling reports fighting with their child when they are angry with each other. This behavior typifies:
- A. coalition
- B. indirect communication
- C. transference
- D. triangulation
Correct Answer: D
Rationale: Triangulation occurs when a third party (the child) is drawn into a conflict between two others, redirecting tension.
Trends that have contributed to the recent increase in eating disorders in the United States include a(n):
- A. more competitive workplace.
- B. increase in the number of divorces.
- C. focus on being thin as a measure of attractiveness.
- D. increase in the number of nonnutritional foods consumed.
Correct Answer: C
Rationale: The correct answer is C: focus on being thin as a measure of attractiveness. This is because societal pressures and media influence have placed a strong emphasis on thinness as the ideal body type, leading to increased body dissatisfaction and disordered eating behaviors. Option A (more competitive workplace) and B (increase in the number of divorces) are not directly linked to eating disorders, while option D (increase in the number of nonnutritional foods consumed) may contribute to health issues but not specifically to eating disorders. In conclusion, the societal focus on thinness has a significant impact on the rise of eating disorders in the United States.
A victim of spousal abuse comes to the emergency department for treatment of a broken arm. She appears hypervigilant and anxious and admits to sleep disturbance when the nurse questions the dark circles under her eyes. She reluctantly tells the nurse the abuse usually occurs when the husband has been drinking, although she concedes he is always jealous and controlling. She is a stay-at-home mother of two preschool children. The family has lived in this town for 1 month. The patient states she has fleetingly considered suicide but must stay alive to care for her children and work her way out of the abusive relationship. She denies any further suicidal thoughts. The nurse should document in the medical record that: (Select all that apply.)
- A. Signs of high anxiety and chronic stress are present.
- B. The patient relies on the perpetrator for basic needs.
- C. The patient has a history of suicidal ideation.
- D. None of the above.
Correct Answer: A
Rationale: The correct answer is A: Signs of high anxiety and chronic stress are present.
Rationale:
1. The patient displaying hypervigilance, anxiety, sleep disturbances, and dark circles under her eyes are indicators of high anxiety and chronic stress, common in victims of abuse.
2. Mentioning abuse occurring when the husband drinks, his jealousy, and control further support the presence of chronic stress and anxiety.
3. The patient's fleeting suicidal thoughts are a response to the abusive situation, not indicative of a history of suicidal ideation.
Summary:
B: The patient relying on the perpetrator for basic needs is not supported by the information provided.
C: There is no indication of a history of suicidal ideation, as the patient's thoughts are tied to her children and escaping the abusive relationship.
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