Nokea
The nurse is admitting a client with schizophrenia. The client is extremely socially withdrawn, is unable to perform activities of daily living, has an inappropriate affect, and has grimacing mannerisms. The nurse understands that this client is experiencing which type of schizophrenia?
- A. residual schizophrenia
- B. paranoid schizophrenia
- C. catatonic schizophrenia
- D. disorganized schizophrenia
- E. undifferentiated schizophrenia
Correct Answer: D
Rationale: Disorganized schizophrenia is characterized by inappropriate affect, social withdrawal, grimacing, and impaired daily functioning.
You may also like to solve these questions
The nurse is assessing a client who was admitted to the hospital with a diagnosis of urinary calculi. The client received 4 mg of morphine sulfate approximately 2 hours previously. The client states to the nurse, 'I'm scared to death that it'll come back.' Based on these statements, which concern should the nurse identify for this client at this time?
- A. Fear of dying
- B. Lack of understanding about the disease process
- C. Anxiety about the anticipation of recurrent severe pain
- D. Retention of urine from the obstruction of the urinary tract by calculi
Correct Answer: C
Rationale: The client stated, 'I'm scared to death that it'll come back.' The anticipation of the recurring pain produces anxiety and threatens the client's psychological integrity. There is no evidence that the client has a calculus in the right ureter. There is also no evidence that the client has lack of knowledge or urinary retention.
A client is telling the nurse about his perception of his thought patterns. Which of the following statements by the client would validate the diagnosis of bipolar disorder?
- A. Sometimes I'm ready to take on the world, but other times I'm too tired to get out of bed.
- B. I need to check and then recheck all the kitchen appliances several times to make sure they are off before I feel comfortable leaving my home.
- C. My neighbors hold sacrificial rites in their backyard.
- D. I keep on patrol all night so the enemy won't invade my home and hurt me or my family.
Correct Answer: A
Rationale: This statement describes mood swings between mania and depression, characteristic of bipolar disorder.
The nurse is admitting a client with schizophrenia. The client is extremely socially withdrawn, is unable to perform activities of daily living, has an inappropriate affect, and has grimacing mannerisms. The nurse understands that this client is experiencing which type of schizophrenia?
- A. residual schizophrenia
- B. paranoid schizophrenia
- C. catatonic schizophrenia
- D. disorganized schizophrenia
- E. undifferentiated schizophrenia
Correct Answer: D
Rationale: Disorganized schizophrenia is characterized by social withdrawal, inappropriate affect, grimacing, and impaired daily functioning. Residual (A) involves milder symptoms, paranoid (B) involves delusions, catatonic (C) involves motor issues, and undifferentiated (E) lacks specific features.
The nurse notes that an assigned client is lying tense in bed and staring at the cardiac monitor. The client states, 'There sure are a lot of wires around there. I sure hope we don't get hit by lightning.' Which is the most appropriate nursing response?
- A. Your family can stay tonight if they wish.'
- B. Would you like a mild sedative to help you relax?'
- C. The hospital is well equipped to shield a lightning strike.'
- D. Yes, all the wires must be scary. Let's talk about the cardiac monitor.'
Correct Answer: D
Rationale: The nurse should initially validate the client's concern and then assess the client's knowledge regarding the cardiac monitor. This gives the nurse an opportunity to provide client education if necessary. None of the remaining options address the client's concern. In addition, pharmacological interventions should be considered only if necessary.
The nurse teaches a group of nursing students about elder abuse. Which older adult client does the nurse list as most likely to be a victim of abuse?
- A. A male diagnosed with moderate hypertension.
- B. A male with newly diagnosed cataracts.
- C. A female with advanced Parkinson disease.
- D. A female diagnosed with early stage Lyme disease.
Correct Answer: C
Rationale: Clients with advanced Parkinson disease are at higher risk for abuse due to increased dependency, physical limitations, and potential cognitive impairments, making them vulnerable to neglect or mistreatment. Other conditions listed are less likely to increase vulnerability to the same extent.