Nokea
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: Rationale for Correct Answer (A): Asking the patient if they trust the nurse to help with the voices is the least impactful at this point because establishing trust should have already been a priority earlier in the hospitalization. The focus now should be on assessing the nature and frequency of the auditory hallucinations to guide further treatment and intervention.
Summary of Incorrect Choices:
B: This question is important to assess if the voices are commanding potentially harmful actions.
C: Understanding the frequency of the voices is crucial in evaluating the severity of the symptoms.
D: Inquiring about hearing voices in different environments helps assess the impact of external factors on the hallucinations.
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An individual accompanied by a friend was brought by ambulance to the emergency room. A nurse notes that the patient's skin is flushed and dry. Further assessment reveals the patient has not voided or ingested food or fluid in 18 hours. Temperature, pulse, blood pressure, and respirations are elevated, and sensorium alternates between clouded and clear. The physician diagnoses fever of unknown origin. Because the patient is restless and agitated, the plan is to make an effort to orally hydrate before attempting to start an IV line. The intervention most likely to be effective will be:
- A. placing a pitcher of water at the patient's bedside.
- B. placing a "force fluids"Â sign at the head of the bed.
- C. asking the friend to give the patient a drink whenever the patient is alert.
- D. staying with the patient to ensure that a glass of liquid is ingested once every hour.
Correct Answer: D
Rationale: The correct answer is D: staying with the patient to ensure that a glass of liquid is ingested once every hour. This choice is the most effective intervention because the patient is in a state of restlessness and agitation, making it crucial to closely monitor fluid intake. By staying with the patient and ensuring regular liquid consumption, the nurse can help maintain hydration and potentially alleviate symptoms.
Choice A (placing a pitcher of water at the patient's bedside) may not be effective as the patient may not be able to independently drink the water when needed. Choice B (placing a "force fluids" sign at the head of the bed) might not address the patient's agitation and restlessness and could lead to increased anxiety. Choice C (asking the friend to give the patient a drink whenever the patient is alert) may not provide consistent monitoring and support needed for the patient's condition.
Therefore, choice D is the best option as it addresses the patient's need for hydration, agitation, and restlessness effectively
What would be an expected outcome for a patient with anorexia nervosa undergoing treatment?
- A. The patient will stabilize weight at a normal level.
- B. The patient will participate in group therapy regularly.
- C. The patient will express satisfaction with their body image.
- D. The patient will regain full cognitive function and independence.
Correct Answer: A
Rationale: The correct answer is A. In Anorexia Nervosa treatment, the primary goal is weight restoration to a healthy level. This is crucial for physical health and recovery. Stabilizing weight at a normal level is a key indicator of treatment success. Choices B, C, and D are incorrect as they do not address the core issue of weight restoration, which is essential in treating Anorexia Nervosa. Group therapy, body image satisfaction, and cognitive function are important aspects of treatment but not the primary outcome measure for patients with anorexia nervosa.
A client who is hospitalized with anorexia nervosa states during a one-to-one session with the nurse, 'I'm freaking out. I'm losing it.' Which nurse response would be most therapeutic at this time?
- A. Would you feel better if I called your parents?'
- B. Just sit here and relax and maintain control.'
- C. Let me sit with you for a while.'
- D. Tell me what thoughts are going through your head.'
Correct Answer: D
Rationale: The correct answer is D because it encourages the client to express their thoughts and feelings, aiding in the therapeutic process. This response promotes open communication and allows the nurse to assess the client's mental state. Choice A may not address the client's immediate distress and could potentially escalate anxiety. Choice B dismisses the client's feelings and does not address the issue. Choice C offers support but does not actively encourage the client to verbalize their thoughts, which is crucial in addressing underlying issues.
A patient states that unit staff members have been avoiding them since an attempt to self-mutilate. The psychiatric-mental health nurse's most appropriate response is to:
- A. apologize for the staff's behavior
- B. explain that feelings of rejection are typical after self-mutilation
- C. listen, redirect the patient to their feelings, and explore the issue with the staff
- D. report the matter to the nurse manager
Correct Answer: C
Rationale: Listening validates the patient, redirecting focuses on their emotions, and exploring with staff addresses care quality.
A community mental health nurse is assigned to investigate the frequent school absences of an 11-year-old child. The nurse finds the child home alone, caring for his 1- and 3-year-old siblings. The house is cluttered and dirty, and both parents are at work. The child tells the nurse that whenever his mother is called to work at her part-time job, he must watch the kids because the family cannot afford a babysitter. Based on the information obtained thus far, what preliminary assessment can be made?
- A. The child is coping well with a difficult situation.
- B. The child and his siblings are experiencing neglect.
- C. The children are at high risk for sexual abuse.
- D. The children are experiencing physical abuse.
Correct Answer: B
Rationale: The correct answer is B: The child and his siblings are experiencing neglect. Neglect is defined as failure to provide for a child's basic needs, such as supervision, food, shelter, and medical care. In this scenario, the child is left alone to care for his younger siblings, indicating a lack of appropriate supervision and care from the parents. The house being cluttered and dirty further suggests neglect in terms of living conditions.
Choice A is incorrect because the child is not coping well; rather, he is forced into a caretaker role beyond his developmental capacity. Choice C is incorrect as there is no information provided to suggest sexual abuse. Choice D is incorrect as there is no evidence of physical abuse in the scenario.