The nurse has been working with a patient diagnosed with schizophrenia who experiences auditory hallucinations. The patient relates, 'When I first heard the voices they said nice things about me. Lately, they've changed and they say bad things.' What information has the least impact on therapeutic patient care at this point in the hospitalization?
- A. Do you trust me to help you with the voices?'
- B. Are the voices commanding you to do something?'
- C. How often during 24 hours do you hear the voices?'
- D. Do you hear the voices if you're busy in noisy environment?'
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
A: Asking about trust in the nurse is not immediately relevant as the patient's primary concern is the change in voice content. Building trust is important but addressing the content of hallucinations takes priority.
B: This is relevant as commanding voices could pose a safety risk.
C: Monitoring frequency helps assess severity and response to treatment.
D: Understanding triggers for hallucinations is important for managing symptoms.
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A patient with severe dementia can no longer recognize her only daughter and becomes anxious and agitated when the daughter attempts to reorient her. An alternative the nurse could suggest to the daughter is to:
- A. Wear a large name tag.
- B. Visit her mother less often.
- C. Talk about experiences they've shared.
- D. None of the above.
Correct Answer: C
Rationale: The correct answer is C: Talk about experiences they've shared. This option is the most appropriate because reminiscing about past shared experiences can help trigger memories and emotions in the patient with dementia, potentially reducing anxiety and agitation. It can provide comfort and a sense of familiarity to the patient. Wearing a large name tag (option A) may not address the core issue of memory loss. Visiting less often (option B) could lead to further feelings of isolation and confusion for the patient. Option D, None of the above, is incorrect as option C provides a constructive and person-centered approach to improving the interaction between the patient and her daughter.
Which of the following procedures can be used to identify Down Syndrome pre-natally?
- A. Amniocentesis
- B. Amnioprolaxis
- C. Amniophalaxi
- D. Amniocalesis
Correct Answer: A
Rationale: Amniocentesis: A procedure extracting and analyzing amniotic fluid to identify Down Syndrome pre-natally in high-risk parents.
A newly admitted patient diagnosed with paranoid schizophrenia is hypervigilant and constantly scans the environment. He states that he saw two doctors talking in the hall and knows they were plotting to kill him. When charting, how should the nurse identify this behavior?
- A. Idea of reference
- B. Delusion of infidelity
- C. Auditory hallucination
- D. Echolalia
Correct Answer: A
Rationale: The correct answer is A: Idea of reference. This patient's belief that the doctors were plotting to kill him is an example of an idea of reference, a symptom of paranoia common in paranoid schizophrenia. This term refers to the belief that neutral actions or events are directed at oneself. Delusion of infidelity (B) involves false beliefs about a partner's infidelity, not relevant here. Auditory hallucination (C) is false perception of sound, not applicable. Echolalia (D) is the repetition of words or phrases, not seen in this scenario. Identifying the behavior as an idea of reference helps the nurse understand the patient's distorted perception and tailor interventions effectively.
A client with catatonic schizophrenia has been posturing, standing with his left arm upraised and his right foot off the floor. For the most part, he ignores attempts at nursing intervention but will occasionally walk, sit, or lie down for a few minutes. The client eats standing up if the nurse brings a tray to the room. The priority nursing order would be to:
- A. Insist that client sit or lie down for 30 minutes hourly
- B. Assess for lower extremity edema bid
- C. Provide high-calorie drinks hourly
- D. Take client to activities therapy once daily
Correct Answer: B
Rationale: The correct answer is B. Assess for lower extremity edema bid.
Rationale:
1. Priority is to assess for lower extremity edema as the client is standing for extended periods, which can lead to edema.
2. Edema assessment is crucial for preventing complications like blood clots or skin breakdown.
3. Insisting on sitting or lying down may aggravate the client and worsen the situation.
4. Providing high-calorie drinks or activities therapy are not the immediate priority in this case.
In summary, assessing for lower extremity edema is crucial due to the client's prolonged standing, which can lead to potential health risks, making it the priority nursing order.
What is the rationale for establishing a contract with a patient with an eating disorder at the outset of treatment?
- A. The patient and nurse form a coalition that is difficult for the family to disrupt.
- B. A team approach to planning therapy ensures that physical and emotional needs will be met.
- C. Patient involvement in decision making increases the sense of control and promotes cooperation.
- D. Permission for refeeding is essential because this measure has the potential for negative effects.
Correct Answer: C
Rationale: Correct Answer: C - Patient involvement in decision making increases the sense of control and promotes cooperation.
Rationale:
1. Involving the patient in decision-making empowers them and enhances their autonomy.
2. Patients with eating disorders often feel a loss of control over their lives, so involving them in treatment decisions can help restore a sense of agency.
3. Increased sense of control can lead to improved cooperation and engagement in treatment.
Summary:
A: Incorrect. Establishing a contract with a patient is not about forming a coalition against the family but about empowering the patient.
B: Incorrect. While a team approach is important, the primary rationale for establishing a contract is to involve the patient in decision-making.
D: Incorrect. Refeeding is important in eating disorder treatment, but the rationale for establishing a contract is more about promoting patient cooperation through involvement in decision-making.