Nokea
The nurse has recently set limits for a patient with borderline personality disorder. The patient tells the nurse, 'You used to care about me. I thought you were wonderful. Now I can see I was mistaken. You're hateful.' Which phenomenon is represented by this response?
- A. Splitting
- B. Denial
- C. Reaction formation
- D. Projection
Correct Answer: A
Rationale: The correct answer is A: Splitting. Splitting is a defense mechanism commonly seen in individuals with borderline personality disorder where they perceive others as either all good or all bad. In this scenario, the patient's sudden shift from viewing the nurse as wonderful to hateful demonstrates splitting. The patient is unable to integrate both positive and negative aspects of the nurse's behavior, leading to extreme and polarized perceptions.
Choice B: Denial involves refusing to accept reality to protect oneself from uncomfortable truths, which is not demonstrated in this response.
Choice C: Reaction formation is a defense mechanism where an individual behaves in a way that is opposite to their true feelings, which is not evident in the patient's response.
Choice D: Projection involves attributing one's own unacceptable thoughts or feelings onto someone else, which is not the case in this scenario.
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A patient was admitted to the mental health unit after arguing with co-workers and threatening to kill them. He is diagnosed with paranoid schizophrenia. On the unit he is aloof and suspicious. He mentioned that two physicians he saw talking were plotting to kill him. On the basis of data gathered at this point, which two primary nursing diagnoses should the nurse consider?
- A. Disturbed thought processes and Risk for other-directed violence
- B. Spiritual distress and Social isolation
- C. Risk for loneliness and Knowledge deficit
- D. Disturbed personal identity and Nonadherence
Correct Answer: A
Rationale: The correct answer is A: Disturbed thought processes and Risk for other-directed violence.
1. Disturbed thought processes: The patient's delusion of being plotted against by the physicians indicates impaired thought processes typical of paranoid schizophrenia.
2. Risk for other-directed violence: The patient's threatening behavior towards co-workers suggests a potential for violent acts towards others due to his paranoid beliefs.
Summary of why other choices are incorrect:
B: Spiritual distress and Social isolation are not primary concerns given the patient's acute symptoms of paranoia and risk for violence.
C: Risk for loneliness and Knowledge deficit are not crucial at this point as the patient's primary issues are related to paranoia and violence.
D: Disturbed personal identity and Nonadherence are not relevant to the immediate safety and mental health concerns presented by the patient.
A client with a borderline personality disorder tells the nurse, 'My doctor tells me there's something wrong with the hard wiring of my brain, and that's why I'm so impulsive and get so many mood swings. He said he's going to prescribe some medication.' Being aware of current practice guidelines, the nurse will prepare a teaching plan for:
- A. Lithium
- B. Fluoxetine
- C. Lorazepam
- D. Haloperidol
Correct Answer: B
Rationale: The correct answer is B: Fluoxetine. Borderline personality disorder (BPD) is primarily treated with psychotherapy, but in some cases, medication is used to manage symptoms like impulsivity and mood swings. Fluoxetine, a selective serotonin reuptake inhibitor (SSRI), is commonly used to address mood instability and impulsivity in BPD. SSRIs help regulate serotonin levels in the brain, which can improve mood stability and decrease impulsive behaviors. Lithium (choice A) is used for bipolar disorder, not BPD. Lorazepam (choice C) is a benzodiazepine used for anxiety and not typically recommended for BPD. Haloperidol (choice D) is an antipsychotic used for conditions like schizophrenia and not typically indicated for BPD.
What is the first intervention a nurse should take when assessing a patient with suspected anorexia nervosa?
- A. Begin refeeding to restore nutritional status.
- B. Measure vital signs to assess the extent of malnutrition.
- C. Start a counseling session to discuss the patient's thoughts on eating.
- D. Involve the family in discussions about treatment plans.
Correct Answer: B
Rationale: The correct answer is B. The first intervention a nurse should take when assessing a patient with suspected anorexia nervosa is to measure vital signs to assess the extent of malnutrition. This is crucial to determine the patient's current physiological status and to identify any immediate risks such as dehydration, electrolyte imbalances, or cardiac complications. By measuring vital signs, the nurse can quickly assess the severity of malnutrition and determine the urgency of intervention. Refeeding (choice A) should not be initiated abruptly due to the risk of refeeding syndrome. Starting a counseling session (choice C) may be important but is not the initial priority. Involving the family (choice D) can be beneficial but is not the first step in assessing and managing a patient with anorexia nervosa.
Which would be the best initial approach for a nurse to select when managing the care of an individual with two children who works full-time and has been abused by a partner?
- A. Teach the individual how to avoid provoking the abuser.
- B. Assist the individual in filing a police report describing the abuse.
- C. Help the individual to identify needs in order to best obtain support.
- D. Facilitate the individual's move into a safe house located near the current workplace.
Correct Answer: C
Rationale: The correct answer is C: Help the individual to identify needs in order to best obtain support. This is the best initial approach because it focuses on understanding the individual's specific needs and circumstances before taking any further action. By identifying needs, the nurse can create a tailored plan to provide appropriate support and resources.
Option A is incorrect because teaching the individual to avoid provoking the abuser places the responsibility on the victim rather than addressing the root cause of the abuse. Option B, filing a police report, may not be the best initial step as it may not take into consideration the individual's safety concerns or emotional well-being. Option D, moving the individual to a safe house, may not be feasible or desired by the individual without first understanding their needs and preferences.
The nurse who works in a sleep clinic knows that approximately __________% of adults experience some form of sleep disorder.
- A. 10 to 20.
- B. 30 to 40.
- C. 50 to 60.
- D. None of the above.
Correct Answer: B
Rationale: The correct answer is B (30 to 40%). This range is supported by research indicating that around 30-40% of adults experience some form of sleep disorder. This percentage reflects the prevalence of various sleep disorders such as insomnia, sleep apnea, and restless leg syndrome among adults. The range of 10 to 20% (choice A) is too low based on current data. Likewise, the range of 50 to 60% (choice C) is too high and does not align with the established prevalence rates of sleep disorders in adults. "None of the above" (choice D) is incorrect as there is a documented prevalence of sleep disorders in adults, making it necessary to provide an estimate within a certain range.