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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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A patient has not come out of her room for breakfast. The nurse finds the patient moving restlessly about her room in a disorganized manner. The patient is talking to herself, and her verbal responses to the nurse are nonsensical and suggest disorientation. The nurse notices that the patient's skin is hot and dry, and her pupils are somewhat dilated. All these symptoms are significant departures from the patient's recent presentation. The patient is likely experiencing ______, and the nurse should ______.
- A. anticholinergic toxicity"¦check vital signs and prepare to use a cooling blanket stat
- B. relapse of her psychosis"¦administer PRN antipsychotic drugs and notify her physician
- C. neuroleptic malignant syndrome"¦contact her physician for a transfer to intensive care
- D. agranulocytosis"¦hold her antipsychotic and draw blood for a complete blood count
Correct Answer: A
Rationale: The correct answer is A: anticholinergic toxicity. The patient's symptoms align with this diagnosis due to the disorganized behavior, nonsensical speech, disorientation, hot and dry skin, dilated pupils, and recent presentation changes. Anticholinergic toxicity can cause confusion, delirium, hyperthermia, and dilated pupils. Checking vital signs and preparing to use a cooling blanket are appropriate actions to manage the symptoms.
Choice B (relapse of psychosis) is incorrect because the symptoms are not typical of a psychotic relapse. Choice C (neuroleptic malignant syndrome) is incorrect as the symptoms do not completely align with this syndrome, which typically includes muscle rigidity and autonomic dysfunction. Choice D (agranulocytosis) is incorrect because it presents with low white blood cell count and not the symptoms described in the scenario.
The average age for onset of anorexia nervosa is:
- A. 13 years old.
- B. 17 years old.
- C. 33 years old.
- D. 40 years old.
Correct Answer: B
Rationale: The correct answer is B (17 years old) because anorexia nervosa typically manifests during adolescence, around ages 15-19. This age range coincides with the developmental stage where body image concerns and societal pressures are heightened. Choice A (13 years old) is too young for the typical onset. Choices C (33 years old) and D (40 years old) are too late for onset, as anorexia nervosa usually begins earlier in life.
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 retirement community and has no close family. The nurse assesses mild dysphasia. The client cannot remember why he has a bandage. He thinks he is in the army and that it is 1950. Appropriate planning for the client should include:
- A. Arranging an appointment at a geriatric assessment program; OT referral for swallowing therapy; teaching to manage public transportation
- B. Attending English class to improve speech; transferring finances to a conservator; employing an aide to help with medications
- C. Arranging Meals on Wheels, attending speech therapy; relocation to a skilled nursing facility if no improvement in 1 month
- D. Assessing diet and meal preparation; assessing environment for safety problems; referral to a dementia program
Correct Answer: D
Rationale: The correct answer, D, is the most appropriate plan because it addresses the client's current needs and safety concerns. Firstly, assessing diet and meal preparation is important due to the client's dysphasia, which may impact their ability to eat safely. Secondly, assessing the environment for safety problems is crucial as the client has dementia and may be at risk of accidents. Lastly, referral to a dementia program is necessary to provide specialized care and support for the client's condition.
Choices A, B, and C are incorrect because they do not directly address the specific needs of the client in terms of dementia, dysphasia, and safety concerns. They focus on unrelated interventions that are not as critical in this scenario.
A client with schizophrenia tells the nurse as they sit in the day room, 'I hear voices telling me bad things.' The most therapeutic response the nurse can make is:
- A. Tell me what the voices are saying.'
- B. I understand you hear these so-called voices, but I hear only the people in the room talking.'
- C. The voices are not real. They're only your imagination.'
- D. Do you think the voices would go away if we went into your room to talk?'
Correct Answer: B
Rationale: The correct answer is B because it demonstrates empathy and validation of the client's experience. By acknowledging the client's reality of hearing voices and emphasizing that the nurse does not hear them, the nurse establishes trust and rapport. This response shows active listening and validates the client's feelings without judgment.
Incorrect responses:
A: Asking the client to describe the voices may increase distress and is not as supportive as acknowledging their experience.
C: Dismissing the voices as not real can invalidate the client's experience and may lead to mistrust.
D: Suggesting a change of location does not address the client's immediate concerns and may not be therapeutic in this situation.
Which of the following is a characteristic behavior in patients with anorexia nervosa?
- A. Binge eating followed by purging.
- B. Extreme weight loss due to excessive food restriction.
- C. Frequent overeating with a lack of control.
- D. Excessive weight gain through overeating and exercise.
Correct Answer: B
Rationale: The correct answer is B: Extreme weight loss due to excessive food restriction. Patients with anorexia nervosa typically exhibit severe food restriction leading to significant weight loss. This behavior is driven by a distorted body image and fear of gaining weight. Binge eating followed by purging (choice A) is characteristic of bulimia nervosa, not anorexia nervosa. Frequent overeating with a lack of control (choice C) is a feature of binge eating disorder, not anorexia nervosa. Excessive weight gain through overeating and exercise (choice D) does not align with the weight loss seen in anorexia nervosa.