Nokea
The most widely used system of psychological classification today is
- A. the Freudian Psychoanalytic System (FPS)
- B. found in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)
- C. the system designed by Emil Kraepelin and Eugen Bleuler
- D. to be found in the Federal Uniform Code of Psychopathology (UCP)
Correct Answer: B
Rationale: The DSM-IV (now DSM-5) is the standard diagnostic system globally used in psychology.
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A 72-year-old client with dementia, who resides in a long-term care facility, frequently goes to her room and cries because she misses her children. This client could benefit most from which intervention?
- A. Life review
- B. Doll therapy
- C. Comfort touch
- D. Audio presence therapy
Correct Answer: D
Rationale: The correct answer is D, Audio presence therapy. This intervention involves playing recordings of loved ones' voices to provide comfort and emotional support. For a client with dementia missing her children, hearing their voices can help reduce feelings of loneliness and provide a sense of connection. Life review (A) may not directly address the client's current emotional needs. Doll therapy (B) and comfort touch (C) may provide some comfort but may not be as effective as directly hearing the voices of her children through audio presence therapy (D).
A patient with schizophrenia repeatedly asks for directions and the time of day. The nurse should:
- A. repeat the information in a kind, matter-of-fact manner.
- B. write out the information so the patient can easily refer to it.
- C. tell the patient that the habit of frequent questioning is annoying.
- D. provide the information once and then remind the patient that the question was already asked.
Correct Answer: A
Rationale: The correct answer is A because patients with schizophrenia may have cognitive impairments affecting memory and orientation, leading to repetitive questioning. By repeating information in a kind, matter-of-fact manner, the nurse can address the patient's needs without causing distress.
Choice B may be helpful, but verbal reinforcement is essential for immediate clarification. Choice C is incorrect as it may exacerbate the patient's distress and worsen the therapeutic relationship. Choice D does not address the underlying cognitive issue and may come across as dismissive.
A client who has been diagnosed as having paranoid schizophrenia is highly suspicious and delusional. He hears voices telling him terrorists are plotting to assassinate him. He refuses to eat, saying the food is poisoned. The nursing action that best addresses his needs is to:
- A. Explain that others eat the food and are not harmed
- B. Allow client to select food from vending machines
- C. Assist client with personal hygiene and grooming
- D. Not allow client to verbalize delusional thoughts
Correct Answer: B
Rationale: The correct answer is B: Allow client to select food from vending machines. This option respects the client's autonomy and addresses his delusion about the food being poisoned. By allowing the client to choose food from vending machines, it acknowledges his concerns and promotes a sense of control over his environment. This approach can help build trust and rapport with the client, as forcing him to eat regular hospital food might exacerbate his paranoia and resistance.
A: Explaining that others eat the food and are not harmed may not be effective as it disregards the client's beliefs and could further alienate him.
C: Assisting with personal hygiene and grooming is important but does not directly address the client's primary concern of refusing to eat due to delusional beliefs.
D: Not allowing the client to verbalize delusional thoughts is counterproductive as it suppresses communication and does not address the underlying issue of the client's fear of being poisoned.
While performing an assessment, the nurse says to a patient, 'While growing up, most of us heard some half-truths about sexual matters that continue to puzzle us as adults. Do any come to your mind now?' The purpose of this question is to
- A. identify areas of sexual dysfunction for treatment.
- B. determine possible homosexual urges.
- C. introduce the topic of masturbation.
- D. identify sexual misinformation.
Correct Answer: D
Rationale: The correct answer is D: identify sexual misinformation. The nurse's question aims to uncover any misconceptions or false information the patient may have received about sexual matters in the past. By identifying these misinformation, the nurse can address and correct them to promote the patient's sexual health and well-being.
Explanation:
1. The nurse's question specifically targets the patient's recollection of "half-truths about sexual matters," indicating a focus on misinformation.
2. By asking the patient if any of these half-truths still puzzle them as adults, the nurse seeks to identify areas where the patient may have received incorrect information.
3. Addressing sexual misinformation is crucial for promoting accurate knowledge, healthy attitudes, and behaviors related to sexuality.
Summary:
A: Incorrect. The question does not directly aim to identify areas of sexual dysfunction for treatment.
B: Incorrect. The question does not target determining possible homosexual urges but rather focuses on uncovering sexual misinformation.
C: Incorrect. The question does not introduce the
An individual accompanied by a sibling was brought by ambulance to the emergency room with suspected impaired cognitive function. The patient's aggressive behavior and attempts to get out of bed present a safety issue. The nurse should first consider:
- A. applying four-point restraints.
- B. using a calm tone to orient the patient.
- C. leaving the patient alone with the sibling.
- D. calling for security guards to hold the patient down.
Correct Answer: B
Rationale: The correct answer is B: using a calm tone to orient the patient. This is the most appropriate initial intervention because it aims to address the patient's aggressive behavior by providing reassurance and attempting to reorient them to their surroundings. Using a calm tone can help de-escalate the situation and improve communication with the patient. Applying four-point restraints (choice A) should be avoided as it is a restrictive measure that should only be used as a last resort to ensure patient safety. Leaving the patient alone with the sibling (choice C) may exacerbate the safety issue, as the sibling may not be equipped to manage the situation. Calling for security guards to hold the patient down (choice D) is a forceful approach that should be avoided until all other options have been exhausted.