Nokea
The client lives so completely in a world of her own that she does not eat, drink, or bathe regularly. She is considered to be:
- A. Exotic
- B. Anorectic
- C. Neurotic
- D. Psychotic
Correct Answer: D
Rationale: The correct answer is D: Psychotic. The client's behavior of not eating, drinking, or bathing regularly indicates a severe detachment from reality, which is a hallmark of psychosis. Psychotic individuals may have delusions or hallucinations that distort their perception of the world, leading to extreme neglect of basic needs. Choices A, B, and C are incorrect because they do not specifically address the profound disconnect from reality exhibited by the client. Exotic refers to something unusual or rare, anorectic relates to an eating disorder, and neurotic typically involves anxiety and emotional instability, none of which fully capture the level of disconnection seen in psychosis.
You may also like to solve these questions
A patient has not come out of her room for breakfast. The nurse finds the patient moving restlessly about her room in a disorganized manner. The patient is talking to herself, and her verbal responses to the nurse are nonsensical and suggest disorientation. The nurse notices that the patient's skin is hot and dry, and her pupils are somewhat dilated. All these symptoms are significant departures from the patient's recent presentation. The patient is likely experiencing ______, and the nurse should ______.
- A. anticholinergic toxicity"¦check vital signs and prepare to use a cooling blanket stat
- B. relapse of her psychosis"¦administer PRN antipsychotic drugs and notify her physician
- C. neuroleptic malignant syndrome"¦contact her physician for a transfer to intensive care
- D. agranulocytosis"¦hold her antipsychotic and draw blood for a complete blood count
Correct Answer: A
Rationale: The correct answer is A: anticholinergic toxicity. The patient's symptoms align with this diagnosis due to the disorganized behavior, nonsensical speech, disorientation, hot and dry skin, dilated pupils, and recent presentation changes. Anticholinergic toxicity can cause confusion, delirium, hyperthermia, and dilated pupils. Checking vital signs and preparing to use a cooling blanket are appropriate actions to manage the symptoms.
Choice B (relapse of psychosis) is incorrect because the symptoms are not typical of a psychotic relapse. Choice C (neuroleptic malignant syndrome) is incorrect as the symptoms do not completely align with this syndrome, which typically includes muscle rigidity and autonomic dysfunction. Choice D (agranulocytosis) is incorrect because it presents with low white blood cell count and not the symptoms described in the scenario.
A person who is the caregiver of a parent with early-to-middle-stage Alzheimer disease is concerned about possible episodes of incontinence. What strategy should the nurse suggest?
- A. Limiting the patient's fluid intake to 1000 ml daily
- B. Discussing the use of an indwelling catheter with the physician
- C. Putting plastic coverings on the beds, upholstered chairs, and sofas
- D. Taking the patient to the bathroom at least every 2 hours when the patient is awake
Correct Answer: D
Rationale: The correct answer is D: Taking the patient to the bathroom at least every 2 hours when the patient is awake. This strategy helps prevent episodes of incontinence by ensuring the patient has regular opportunities to void. It promotes continence through scheduled toileting, maintaining the patient's dignity and preventing accidents.
Choice A is incorrect as restricting fluid intake can lead to dehydration and other health issues. Choice B is incorrect because indwelling catheters are not recommended for managing incontinence in Alzheimer's patients due to the risk of urinary tract infections. Choice C is incorrect as it only addresses the aftermath of incontinence, not the prevention of it.
A nurse finds a patient with anorexia nervosa vigorously exercising before gaining the agreed-upon weekly weight. Select the nurse's best comment.
- A. It bothers me to see you exercising.
- B. You and I will have to sit down and discuss this problem.
- C. Let's discuss the relationship between exercise and weight loss and how that affects your body.
- D. According to our agreement, exercising is not permitted until you have gained a specific amount of weight.
Correct Answer: D
Rationale: The correct answer is D because it directly addresses the behavior in relation to the agreed-upon plan and sets clear boundaries. By stating that exercising is not permitted until the patient has gained a specific amount of weight, the nurse reinforces the importance of following the treatment plan to ensure the patient's health and well-being.
A: This response does not address the behavior in a constructive manner and may come across as judgmental.
B: While discussing the problem is important, it does not provide clear guidance on addressing the immediate issue of exercising before reaching the weight goal.
C: While discussing the relationship between exercise and weight loss can be helpful, it does not provide a clear directive on what action should be taken in this specific situation.
A boy with a conduct disorder diagnosis would be most likely to have which symptom?
- A. Withdrawal
- B. Ritualistic behavior
- C. Class bully
- D. Class clown
Correct Answer: C
Rationale: A pattern of bullying is a common sign of conduct disorder. Responses A and B may reflect autism.
The nurse has been working with a patient diagnosed with schizophrenia who experiences auditory hallucinations. The patient relates, 'When I first heard the voices they said nice things about me. Lately, they've changed and they say bad things.' What information has the least impact on therapeutic patient care at this point in the hospitalization?
- A. Do you trust me to help you with the voices?'
- B. Are the voices commanding you to do something?'
- C. How often during 24 hours do you hear the voices?'
- D. Do you hear the voices if you're busy in noisy environment?'
Correct Answer: A
Rationale: Rationale for Correct Answer (A): Asking the patient if they trust the nurse to help with the voices is the least impactful at this point because establishing trust should have already been a priority earlier in the hospitalization. The focus now should be on assessing the nature and frequency of the auditory hallucinations to guide further treatment and intervention.
Summary of Incorrect Choices:
B: This question is important to assess if the voices are commanding potentially harmful actions.
C: Understanding the frequency of the voices is crucial in evaluating the severity of the symptoms.
D: Inquiring about hearing voices in different environments helps assess the impact of external factors on the hallucinations.