Nokea
The client tells the nurse, 'My husband left to go bowling with his buddies, so I had to cut myself.' The nurse using the SET method of communication will use as the initial response:
- A. Tell me what made you think of that action.'
- B. It concerns me to hear that you took that action.'
- C. You should have called your psychiatrist.'
- D. What can I do to help you now that you're here?'
Correct Answer: B
Rationale: The correct answer is B: "It concerns me to hear that you took that action." The rationale for this is that this response demonstrates empathy and concern for the client's well-being, which is essential in building a therapeutic relationship. It acknowledges the client's statement without judgment and opens the door for further exploration of the client's feelings and reasoning behind the self-harm.
Choice A: "Tell me what made you think of that action" may come across as too direct and could be perceived as insensitive or confrontational, potentially shutting down communication.
Choice C: "You should have called your psychiatrist" is dismissive and fails to address the client's emotional needs or offer support.
Choice D: "What can I do to help you now that you're here?" is forward-thinking and assumes the client is seeking help, which may not be the case. It also does not directly address the concerning behavior of self-harm.
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Which complication is most likely in a patient with bulimia nervosa who purges frequently?
- A. Dehydration and electrolyte imbalances.
- B. Increased appetite and weight gain.
- C. Improved digestion and nutrient absorption.
- D. High blood pressure and rapid heart rate.
Correct Answer: A
Rationale: The correct answer is A: Dehydration and electrolyte imbalances. Purging in bulimia nervosa involves self-induced vomiting or misuse of laxatives, leading to fluid and electrolyte loss. This can result in dehydration, electrolyte imbalances, and potentially life-threatening complications like cardiac arrhythmias. Increased appetite and weight gain (B) are less likely due to purging. Improved digestion and nutrient absorption (C) are not associated with frequent purging. High blood pressure and rapid heart rate (D) may occur in severe cases but are not the most likely complication.
A client has been admitted with disorganized type schizophrenia. The nurse observes blunted affect and social isolation. He occasionally curses or calls another client a 'jerk' without provocation. The nurse asks the client how he is feeling, and he responds, 'Everybody picks on me. They frobitz me.' The nurse would assess 'frobitz' as:
- A. Circumstantial speech
- B. Loose associations
- C. Evidence of delusional thinking
- D. A neologism
Correct Answer: D
Rationale: The correct answer is D: A neologism. A neologism is a newly coined word or expression that is not easily understood by others. In this case, the client's use of the word 'frobitz' is not a recognized word, indicating it may be a neologism. This is commonly seen in individuals with schizophrenia who create new words or distort existing ones.
A: Circumstantial speech involves excessive and unnecessary details before reaching the main point. The client's response is not characterized by this.
B: Loose associations involve a lack of logical connections between thoughts. The client's response is not demonstrating this.
C: Evidence of delusional thinking would involve fixed, false beliefs that are not based in reality. The client's use of 'frobitz' does not necessarily indicate a delusion.
In summary, the use of 'frobitz' by the client is indicative of a neologism, as it is a new and potentially meaningless
The outcome that should be established for an elderly patient with delirium caused by fever and dehydration is that the patient will:
- A. Return to a premorbid level of functioning.
- B. Demonstrate motor responses to noxious stimuli.
- C. Identify stressors negatively affecting self.
- D. None of the above.
Correct Answer: A
Rationale: The correct answer is A because the goal in managing delirium in an elderly patient is to restore them to their premorbid level of functioning. This involves addressing the underlying causes like fever and dehydration. Option B is incorrect as it focuses on a neurological response rather than the overall outcome for the patient. Option C is also incorrect as it pertains to identifying stressors, which is not the primary goal in managing delirium. Option D is incorrect as it dismisses the importance of restoring the patient to their baseline level of functioning.
A nurse is planning care for a patient with bulimia nervosa. Which goal should be included in the care plan?
- A. The patient will engage in daily exercise to prevent weight gain.
- B. The patient will maintain a healthy, balanced diet without purging behaviors.
- C. The patient will gain 1-2 pounds per week.
- D. The patient will eliminate binge eating and purging behaviors entirely.
Correct Answer: B
Rationale: Step-by-step rationale:
1. Maintaining a healthy, balanced diet without purging behaviors is crucial for managing bulimia nervosa.
2. This goal promotes physical health and addresses the underlying disordered eating habits.
3. It focuses on establishing sustainable eating patterns to support overall well-being.
4. It helps prevent complications associated with bulimia, such as electrolyte imbalances.
Summary:
- Option A is incorrect as excessive exercise can be a compensatory behavior in eating disorders.
- Option C is incorrect as rapid weight gain is not recommended in the treatment of bulimia.
- Option D is incorrect as complete elimination of binge eating and purging may be unrealistic initially.
A patient received maintenance doses of fluphenazine decanoate (Prolixin Decanoate) 25 mg IM every 2 weeks for 2 years. The clinic nurse notes the patient is grimacing and seems to be constantly smacking her lips. On the next clinic visit, the patient's neck and shoulders twist in a slow, snakelike motion. The nurse should suspect the presence of ______ and should ______.
- A. agranulocytosis"¦check the patient's complete blood count for changes
- B. tardive dyskinesia"¦administer the Abnormal Involuntary Movement Scale
- C. Tourette's syndrome"¦consult the patient's physician about a neuro evaluation
- D. anticholinergic effects"¦consult the physician about possible medication changes
Correct Answer: B
Rationale: The correct answer is B: tardive dyskinesia"¦administer the Abnormal Involuntary Movement Scale.
1. Tardive dyskinesia is a side effect of long-term use of antipsychotic medications like fluphenazine.
2. The symptoms described - grimacing, lip smacking, twisting neck and shoulders - are characteristic of tardive dyskinesia.
3. Administering the Abnormal Involuntary Movement Scale is the appropriate assessment tool for diagnosing tardive dyskinesia.
4. Agranulocytosis (choice A) is a rare but serious side effect of some antipsychotic medications, not associated with the symptoms described.
5. Tourette's syndrome (choice C) typically presents with vocal and motor tics, not the specific symptoms mentioned.
6. Anticholinergic effects (choice D) can cause dry mouth, constipation, and blurred vision, but not the involuntary movements described.