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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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After taking an antidepressant for about a week, a patient reports constipation and blurred vision, with no improvement in mood. The psychiatric-mental health nurse informs the patient,:
- A. It takes approximately two to four weeks for depression to lessen, and side effects usually diminish over time'
- B. Stop the medication immediately and contact your primary care physician'
- C. You should contact your doctor. The doctor may need to change your medication'
- D. You should schedule an appointment with your ophthalmologist'
Correct Answer: A
Rationale: Antidepressants require 2-4 weeks for therapeutic effect, and early side effects often subside, making this the most reassuring response.
Which of the following is a characteristic of anorexia nervosa?
- A. Binge eating followed by purging.
- B. Refusal to maintain a healthy weight and an intense fear of gaining weight.
- C. Frequent overeating episodes without purging behaviors.
- D. Extreme preoccupation with body image and excessive exercise.
Correct Answer: B
Rationale: The correct answer is B because anorexia nervosa involves a refusal to maintain a healthy weight, an intense fear of gaining weight, and a distorted body image. This disorder is characterized by restrictive eating habits leading to significant weight loss. Individuals with anorexia nervosa often perceive themselves as overweight despite being underweight. Choices A, C, and D are incorrect as they describe characteristics more closely associated with bulimia nervosa, binge eating disorder, and orthorexia, respectively. Binge eating followed by purging (A) is a behavior seen in bulimia nervosa, frequent overeating episodes without purging (C) is typical of binge eating disorder, and extreme preoccupation with body image and excessive exercise (D) may be seen in orthorexia or other eating disorders, but not specifically in anorexia nervosa.
The client is describing her trip to town. She tells the nurse, 'I cold town yellow water girl outside below ground.' This speech disturbance is called:
- A. Neologism
- B. Word salad
- C. Flight of ideas
- D. Verbigeration
Correct Answer: B
Rationale: The correct answer is B: Word salad. This speech disturbance is characterized by a jumble of words that lack coherent meaning or connection. In this case, the client's words are disorganized and nonsensical. Neologism (A) is the creation of new words, not a jumble of existing words. Flight of ideas (C) involves rapid shifts in thoughts without a clear connection, not a jumble of words. Verbigeration (D) is the constant repetition of words or phrases, not a jumble of unrelated words.
A friend brings a teenager to the emergency department. The friend found the patient unconscious in a bedroom at a party. Semen is observed on the patient's underclothes. Priority actions by the nurse should focus on:
- A. Preserving rape evidence.
- B. Maintaining the patient's airway.
- C. Obtaining a description of the rape.
- D. Determining what drugs were ingested.
Correct Answer: B
Rationale: The correct answer is B: Maintaining the patient's airway. This is the priority action because the patient is unconscious and airway patency is crucial for survival. Preserving rape evidence (A) can be important, but the patient's immediate health takes precedence. Obtaining a description of the rape (C) can wait until the patient's condition stabilizes. Determining what drugs were ingested (D) is important but secondary to ensuring the patient can breathe.
A drug causes muscarinic receptor blockade. The nurse will assess the patient for
- A. Dry mouth.
- B. Gynecomastia.
- C. Pseudoparkinsonism.
- D. Orthostatic hypotension.
Correct Answer: A
Rationale: The correct answer is A: Dry mouth. Muscarinic receptor blockade inhibits the action of acetylcholine, leading to decreased salivary gland secretion and causing dry mouth. Gynecomastia (B) is associated with antiandrogen medications. Pseudoparkinsonism (C) is a side effect of antipsychotic medications that block dopamine receptors. Orthostatic hypotension (D) is a side effect of alpha-1 adrenergic receptor blockade.