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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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Schizophrenia in children as young as 5 years:
- A. Is a myth
- B. Can occur
- C. Never occurs
- D. Cannot occur
Correct Answer: B
Rationale: The correct answer is B: Can occur. Schizophrenia can indeed manifest in children as young as 5 years old, although it is rare. Symptoms may include hallucinations, delusions, disorganized speech, and impaired social interactions. Early diagnosis and intervention are crucial for managing the condition. Choice A is incorrect as schizophrenia in young children is not a myth. Choice C is incorrect as schizophrenia can occur in children. Choice D is incorrect as there have been documented cases of schizophrenia in children as young as 5 years old.
A nurse observes a patient who is sitting alone in a room put hands over both ears and vigorously shake her head as though saying, 'No.' Later the patient cries and mutters, 'You don't know what you're talking about! Leave me alone.' What assessment should the nurse attempt to validate?
- A. The patient is seeking the attention of staff.
- B. The patient is inappropriately expressing emotion.
- C. The patient is experiencing auditory hallucinations.
- D. The patient is displaying negative symptoms of schizophrenia.
Correct Answer: C
Rationale: The correct answer is C: The patient is experiencing auditory hallucinations. The patient's behavior of covering both ears and shaking her head as if responding to voices, along with muttering and crying, suggests a sensory perception that is not based on external stimuli. This aligns with the characteristic symptoms of auditory hallucinations, which are common in conditions like schizophrenia.
Choice A is incorrect because the patient's behavior is not necessarily seeking attention but rather responding to internal stimuli. Choice B is incorrect as the patient's emotional expression seems to be a result of the auditory hallucinations rather than being inappropriate. Choice D is incorrect as negative symptoms of schizophrenia typically involve a decrease or absence of normal functions, which is not clearly demonstrated in this scenario.
To cope with the devastating effects of schizophrenia and other serious mental illnesses, family members or significant others and clients will benefit most from:
- A. Regular psychoanalysis
- B. Intensive short-term therapy
- C. Ongoing treatment and support
- D. Continued medication adjustments
Correct Answer: C
Rationale: The correct answer is C: Ongoing treatment and support. This option is the most beneficial for coping with serious mental illnesses like schizophrenia because it involves long-term management and assistance. Ongoing treatment can include therapy, medication management, and support groups, which are crucial for helping individuals and their families manage symptoms and improve overall quality of life.
Explanation:
A: Regular psychoanalysis is not the most effective approach for managing the devastating effects of serious mental illnesses like schizophrenia. It may not provide the immediate support and intervention needed for crisis situations.
B: Intensive short-term therapy may offer temporary relief, but ongoing treatment and support are essential for long-term management and stability.
D: Continued medication adjustments are important, but they are just one aspect of a comprehensive treatment plan. Ongoing treatment and support encompass a broader range of interventions that are necessary for addressing the complex needs of individuals with serious mental illnesses.
An 82-year-old widow with Alzheimer's disease lives with her daughter's family, which owns a catering business. During the week, the patient attends a daycare center for patients. During the evenings, members of the family care for the patient. One day, the nurse at the daycare center notices the patient's appearance is disheveled and that she has bruises on her wrists and back when escorted to the bathroom. What most likely explains the nurse's observations?
- A. The patient is being neglected and abused within the family.
- B. The dementia is progressing, reducing self-care and increasing falls.
- C. The patient is experiencing normal aging symptoms.
- D. The patient is suffering from a new medical condition.
Correct Answer: A
Rationale: The correct answer is A because the nurse's observations of disheveled appearance, bruises, and signs of physical abuse indicate possible neglect and abuse within the family. This is supported by the presence of Alzheimer's disease, vulnerability due to age, and the patient's living situation with family members who own a catering business. Choice B is incorrect as it does not explain the bruises and neglect observed. Choice C is incorrect as normal aging symptoms would not typically include bruises and neglect. Choice D is incorrect as there is no indication of a new medical condition causing these specific observations.
During occupational therapy a young patient diagnosed with schizophrenia sits staring at a piece of paper. Which response is most therapeutic at this time?
- A. If you prefer to sit and stare for a time, it is acceptable for you to leave.'
- B. You seem immobilized by anxiety. Is there anything I can do to help?'
- C. Are you having trouble deciding where you want to glue that piece?'
- D. Rub the glue stick on the back of the paper.'
Correct Answer: D
Rationale: The correct answer is D because it provides a clear and simple directive that guides the patient on what to do next, promoting engagement in the therapeutic activity. By instructing the patient to rub the glue stick on the back of the paper, it helps redirect their focus and encourages participation in the task.
Choice A is incorrect as it allows the patient to disengage from the activity, which does not promote therapeutic progress. Choice B assumes the patient is anxious without evidence and may not address the core issue. Choice C is incorrect as it may not be relevant to the patient's current state and may further confuse or frustrate them.