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The intervention of highest priority for a client with stage 3 Alzheimer's disease is to:
- A. Provide a stimulating environment
- B. Maintain hydration and nutrition
- C. Set limits on behavioral disinhibition
- D. Promote self-care activities
Correct Answer: B
Rationale: The correct answer is B because maintaining hydration and nutrition is crucial for the client's overall well-being and health in stage 3 Alzheimer's. Dehydration and malnutrition can lead to serious complications. Providing a stimulating environment (choice A) may be beneficial but not the highest priority. Setting limits on behavioral disinhibition (choice C) may be challenging due to the progression of the disease. Promoting self-care activities (choice D) may not be feasible as the client's cognitive abilities decline. Maintaining hydration and nutrition is essential for the client's survival and quality of life.
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In the powerpoint activity for this lesson, you witnessed photographs of typical weekly food consumptions for families in various countries. Which country depicted a photograph of a family who consumed the LEAST amount of fruits and vegetables and the MOST amount of processed food?
- A. Germany
- B. Poland
- C. Chad
- D. United States
Correct Answer: D
Rationale: The United States is often depicted with diets high in processed foods and low in fruits and vegetables, reflecting modern consumption patterns.
A client admitted with delusions, hallucinations, and thought disorder has the admitting diagnosis schizophreniform disorder R/O organic pathology. Based on this information, the nurse can expect that the client will:
- A. Undergo an MRI test
- B. Have psychological testing
- C. Have an immunologic assay performed
- D. Participate in a dexamethasone suppression test
Correct Answer: A
Rationale: Step 1: The client is admitted with symptoms suggestive of a psychotic disorder, specifically schizophreniform disorder.
Step 2: The admitting diagnosis includes ruling out organic pathology, indicating a need to investigate potential physical causes.
Step 3: An MRI test is a non-invasive imaging procedure that can help identify any structural abnormalities in the brain.
Step 4: This test is appropriate in ruling out organic causes of the symptoms presented by the client.
Step 5: Psychological testing (Choice B) is more focused on assessing cognitive and emotional functioning, not ruling out organic pathology.
Step 6: Immunologic assay (Choice C) is used to detect antibodies or antigens in the blood, not typically relevant in this context.
Step 7: Dexamethasone suppression test (Choice D) is used to assess for abnormalities related to cortisol levels in conditions like depression, not specific to ruling out organic pathology in psychotic disorders.
Summary: Choice A is correct because an MRI test is the most relevant
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 created word or phrase that is unique to the individual and not understandable to others. In this scenario, the client's use of the word 'frobitz' is an example of a neologism. This demonstrates disorganized thinking and language typical of schizophrenia.
A: Circumstantial speech involves providing unnecessary details before reaching the main point, which is not evident in the client's response.
B: Loose associations involve a lack of logical connection between thoughts, which is not demonstrated by the client's use of 'frobitz.'
C: Delusional thinking involves fixed false beliefs, which are not explicitly present in the client's response.
In summary, the client's use of 'frobitz' indicates a neologism, reflecting disorganized thinking in schizophrenia, making it the correct assessment.
A family has noted the following behaviors in one of their elderly parents: periodic indecisiveness, forgetfulness, mild transient confusion, occasional misperception, distractibility, and occasional unclear thinking. Where on the continuum of cognitive responses would this patient be?
- A. At point 1
- B. At point 2
- C. At point 3
- D. There is insufficient information to make a determination.
Correct Answer: B
Rationale: The correct answer is B: At point 2. This patient's symptoms indicate mild cognitive impairment, which falls between normal age-related decline (point 1) and dementia (point 3). Mild cognitive impairment involves noticeable cognitive changes but does not significantly interfere with daily functioning. Point 1 is too mild for the symptoms described, and point 3 is too severe as the patient's symptoms are not indicative of full-blown dementia. Therefore, the patient is best placed at point 2 on the continuum of cognitive responses.
An adult consulted a nurse practitioner because of an inability to achieve orgasm for 2 years, despite having been sexually active. This adult was frustrated and expressed concerns about the relationship with the sexual partner. Which documentation best indicates the treatment was successful?
- A. No complaints related to sexual function; to return next week.
- B. Patient reports achieving orgasm last week; seems very happy.
- C. Reports satisfaction with sexual encounters; feels partner is supportive.
- D. Reports achieving orgasm occasionally; relationship with partner is adequate.
Correct Answer: C
Rationale: Step 1: Choice C indicates satisfaction with sexual encounters and feeling supported by the partner, which suggest a positive outcome in addressing the inability to achieve orgasm and concerns about the relationship.
Step 2: The patient feeling satisfied and supported signifies improvement in sexual function and relationship dynamics.
Step 3: This documentation reflects a holistic approach to addressing the patient's concerns, focusing on emotional well-being and relationship quality.
Step 4: Overall, choice C demonstrates a comprehensive resolution to the patient's initial complaints and indicates successful treatment.
Summary:
Choice C is the correct answer as it shows improvement in both sexual function and relationship satisfaction. Choices A, B, and D do not address the patient's concerns about the relationship or emotional well-being, making them less appropriate indicators of treatment success.