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The home care nurse assessed a client with a history of dementia who had a herniorrhaphy at an ambulatory surgical center the previous day. The client lives in a senior living facility. The client thinks he is in the army and that it is 1945. The nurse should:
- A. Reorient the client to the current time and place.
- B. Notify the client's family of the confusion.
- C. Document the client's confusion and disorientation.
- D. None of the above.
Correct Answer: A
Rationale: The correct answer is A: Reorient the client to the current time and place. The nurse should reorient the client to prevent distress and promote safety. This approach helps the client feel more secure and may reduce confusion. Choice B is incorrect because the nurse should address the client's needs first. Choice C is not enough on its own as the nurse needs to actively assist the client. Choice D is incorrect as action is needed in this situation to support the client.
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A 72-year-old patient has the medical diagnosis of delirium secondary to anticholinergic medication toxicity. Family members are very anxious and express their concerns about the patient's condition. What information should serve as the basis for the nurse's reply?
- A. Provide education and information regarding the medical diagnosis, delirium secondary to anticholinergic medication toxicity.
- B. Reassure the family that the patient will recover fully.
- C. Suggest that the family consider nursing home placement.
- D. None of the above.
Correct Answer: A
Rationale: The correct answer is A. The nurse should provide education and information about the medical diagnosis, delirium secondary to anticholinergic medication toxicity. This is important because it helps the family understand the condition, its causes, symptoms, and treatment. By educating the family, they can better support the patient and be involved in the care plan.
Choice B is incorrect because it provides false reassurance without addressing the underlying issue or providing necessary information.
Choice C is incorrect because suggesting nursing home placement is premature and not based on the patient's current condition or needs.
Therefore, the best approach is to choose option A to empower the family with knowledge and understanding to better assist the patient.
A patient with bipolar disorder has rapid cycles. To prepare teaching materials, the nurse anticipates which medication will be prescribed?
- A. Clonidine (Catapres)
- B. Phenytoin (Dilantin)
- C. Carbamazepine (Tegretol)
- D. Chlorpromazine (Thorazine)
Correct Answer: C
Rationale: Rationale: Carbamazepine (Tegretol) is commonly used in treating rapid cycling bipolar disorder due to its mood stabilizing properties. It helps regulate mood swings and prevent manic or depressive episodes. It is effective in managing rapid cycling symptoms. Clonidine (A) is used for ADHD and hypertension, not bipolar disorder. Phenytoin (B) is an anticonvulsant, not typically used for bipolar disorder. Chlorpromazine (D) is an antipsychotic mainly for schizophrenia, not specifically indicated for rapid cycling in bipolar disorder.
Behavioral problems in which the person exhibits symptoms suggesting physical disease or injury, but for which there is no identifiable cause, are called
- A. mood disorders
- B. schizophrenia
- C. organic brain pathologies
- D. somatoform disorders
Correct Answer: D
Rationale: Somatoform disorders feature physical complaints without medical explanation.
A patient admitted to the eating disorders unit has yellow skin, the extremities are cold, and the heart rate is 42 bpm. The patient weighs 70 pounds; height is 5 feet 4 inches. The patient is quiet during the assessment saying only, "I will not eat until I lose enough weight to look thin."Â Select the best initial nursing diagnosis.
- A. Anxiety related to fear of weight gain
- B. Disturbed body image related to weight loss
- C. Ineffective coping related to lack of conflict resolution skills
- D. Imbalanced nutrition: less than body requirements related to self-starvation
Correct Answer: D
Rationale: The correct initial nursing diagnosis is D: Imbalanced nutrition: less than body requirements related to self-starvation. The patient's presentation of yellow skin, cold extremities, bradycardia, low weight, and refusal to eat indicate severe malnutrition due to self-starvation. The key indicators are the physical signs of malnutrition and the patient's statement about not eating until they lose enough weight. Options A and B do not address the primary issue of malnutrition and self-starvation. Option C focuses on coping skills, which is not the priority in this case. Therefore, option D is the best initial nursing diagnosis to address the patient's life-threatening condition of malnutrition.
A client who is diagnosed with schizoid personality disorder is isolative, does not speak to her peers, and sits through the community meeting without speaking. Her mother describes her as shy and having few friends. Which would be an appropriate nursing diagnosis for this client?
- A. Anxiety related to a new environment as evidenced by isolation and not talking with peers
- B. Impaired social interaction related to unfamiliar environment as evidenced by isolation and not talking with peers
- C. Ineffective coping related to new environment as evidenced by isolation and minimal interaction with others
- D. Disturbed thought processes related to a new environment as evidenced by isolation and minimal interactions with others
Correct Answer: B
Rationale: The correct answer is B: Impaired social interaction related to unfamiliar environment as evidenced by isolation and not talking with peers. This is the most appropriate nursing diagnosis for the client because it accurately reflects the client's behavior of isolation and lack of communication with peers, which are indicative of impaired social interaction.
Rationale:
1. Impaired social interaction is a key characteristic of schizoid personality disorder, as individuals with this disorder tend to be socially isolated and have difficulty forming relationships.
2. The client's behavior of not speaking to peers and sitting through meetings without interaction supports the diagnosis of impaired social interaction.
3. The description of the client by her mother as shy and having few friends further supports the diagnosis of impaired social interaction.
Summary:
A: Anxiety related to a new environment is incorrect because the client's behavior is more indicative of impaired social interaction rather than anxiety.
C: Ineffective coping related to new environment is incorrect as there is no evidence to suggest that the client is using maladaptive coping