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The daughter of an 84-year-old client with dementia tearfully tells the nurse that she doesn't know what's wrong with her mother, who has begun accusing the family of stealing her lingerie and holding her prisoner. The nurse assesses the client's stage of Alzheimer's disease as stage:
- A. 1
- B. 2
- C. 3
- D. 4
Correct Answer: B
Rationale: The correct answer is B (stage 2) because the client is exhibiting symptoms of moderate Alzheimer's disease, such as paranoia and delusions. In stage 2, cognitive decline becomes more noticeable, leading to memory loss, confusion, and behavioral changes. The client's accusations and false beliefs indicate a decline in reality orientation, which is characteristic of stage 2. Choices A, C, and D are incorrect because stage 1 is characterized by mild cognitive decline, stage 3 by severe cognitive decline, and stage 4 by very severe cognitive decline.
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A 35-year-old woman who is being interviewed by the advanced practice nurse indicates that she has few friends, fears criticism from others, and withholds information about her thoughts and feelings because she anticipates a negative reaction. Based on these data, the nurse suspects that Sarah may later be diagnosed as having:
- A. Borderline personality disorder
- B. Histrionic personality disorder
- C. Avoidant personality disorder
- D. Schizoid personality disorder
Correct Answer: C
Rationale: The correct answer is C: Avoidant personality disorder. This is because the woman's fear of criticism, reluctance to share thoughts and feelings, and limited social interactions are characteristic of avoidant personality disorder. Individuals with this disorder have intense feelings of inadequacy, fear of rejection, and avoid situations where they may be criticized or judged.
Choice A: Borderline personality disorder is not the correct answer because individuals with borderline personality disorder typically have unstable relationships, impulsivity, and a fear of abandonment.
Choice B: Histrionic personality disorder is not the correct answer as individuals with this disorder seek attention and exhibit dramatic and attention-seeking behavior, which is not indicated in the scenario.
Choice D: Schizoid personality disorder is not the correct answer as individuals with this disorder tend to have a limited range of emotional expression and lack interest in forming social relationships, which does not align with the woman's fear of criticism and desire to avoid negative reactions.
Anorexia nervosa is best described as a disorder that is potentially:
- A. serious.
- B. uncommon.
- C. psychiatric.
- D. life threatening.
Correct Answer: D
Rationale: The correct answer is D: life threatening. Anorexia nervosa is a serious eating disorder characterized by extreme restriction of food intake, leading to significant weight loss and potentially life-threatening consequences such as organ damage, heart problems, and even death. It is crucial to recognize the severity of anorexia nervosa as it can have devastating effects on physical and mental health. Choices A and C are partially correct, as anorexia nervosa is serious and psychiatric, but they do not fully capture the potential severity and life-threatening nature of the disorder. Choice B is incorrect as anorexia nervosa is not uncommon, affecting a significant number of individuals worldwide.
Which of the following should be considered in the assessment of oppositional behaviours in children?
- A. Peer relationships
- B. Child s developmental stage
- C. Behaviours exhibited at home
- D. All of the above
Correct Answer: D
Rationale: All factorsâ€â€peer relationships, developmental stage, home behavior, and family historyâ€â€are critical in assessing oppositional behaviors comprehensively.
A patient was admitted to the mental health unit after arguing with co-workers and threatening to kill them. He is diagnosed with paranoid schizophrenia. On the unit he is aloof and suspicious. He mentioned that two physicians he saw talking were plotting to kill him. On the basis of data gathered at this point, which two primary nursing diagnoses should the nurse consider?
- A. Disturbed thought processes and Risk for other-directed violence
- B. Spiritual distress and Social isolation
- C. Risk for loneliness and Knowledge deficit
- D. Disturbed personal identity and Nonadherence
Correct Answer: A
Rationale: The correct answer is A: Disturbed thought processes and Risk for other-directed violence.
1. Disturbed thought processes: The patient's delusion of being plotted against by the physicians indicates impaired thought processes typical of paranoid schizophrenia.
2. Risk for other-directed violence: The patient's threatening behavior towards co-workers suggests a potential for violent acts towards others due to his paranoid beliefs.
Summary of why other choices are incorrect:
B: Spiritual distress and Social isolation are not primary concerns given the patient's acute symptoms of paranoia and risk for violence.
C: Risk for loneliness and Knowledge deficit are not crucial at this point as the patient's primary issues are related to paranoia and violence.
D: Disturbed personal identity and Nonadherence are not relevant to the immediate safety and mental health concerns presented by the patient.
The most severe psychological disorder is a(n)
- A. personality disorder
- B. psychosomatic illness
- C. anxiety disorder
- D. psychosis
Correct Answer: D
Rationale: Psychosis, involving severe reality distortion, is considered the most debilitating class of disorders.