Nokea
The nurse is discharging four clients from the behavioral health unit. Which client would be the best candidate for long-term inpatient care?
- A. The client experiencing hallucinations
- B. The client with feelings of persecution
- C. The client with a love interest
- D. The client with suspicion and anger
Correct Answer: D
Rationale: Once a client is in the mental health system, every effort is made to avoid institutionalization. The exception is when the client is dangerous to self and others. The nurse is most correct to anticipate the client with suspicion and anger to be the best candidate for long-term inpatient care. Clients who have hallucinations or feelings of persecution and those with a love interest being discharged from a behavioral health unit can be monitored in an outpatient setting.
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Which of the following is the primary reason for monitoring food and fluid intake and toilet patterns of a client with mental disabilities?
- A. Regular checkup
- B. To identify problems
- C. To determine common symptoms
- D. Physician's record
Correct Answer: B
Rationale: The nurse monitors food and fluid intake and toilet patterns because data collection facilitates problem identification, not as part of a regular checkup or for determining common symptoms. The physician may refer to these records whenever required.
A client diagnosed with schizophrenia is constantly repeating what others say. The nurse would document these symptoms as which of the following?
- A. Loose associations
- B. Delusions
- C. Echolalia
- D. Neologism
Correct Answer: C
Rationale: Echolalia is repeating what others say. Loose associations are a sequence of ideas that are slightly connected. Delusions are false beliefs that cannot be changed by logical reasoning. Neologism is the inventing of new words.
A client is taking a traditional antipsychotic medication and is exhibiting grimacing and lip smacking. The nurse would document this side effect as which of the following?
- A. Akinesia
- B. Akathisia
- C. Tardive dyskinesia
- D. Dystonia
Correct Answer: C
Rationale: Tardive dyskinesia occurs when the client makes involuntary muscle movements, usually in the face, such as tongue thrusting, lip smacking, or blinking. Akinesia is pseudo parkinsonism. Akathisia is the inability to sit still. Dystonia is a sudden severe muscle spasm, usually in the neck, tongue, or eyes.
Which of the following nursing diagnoses would be of highest priority for a client diagnosed with advanced Alzheimer disease?
- A. Chronic Confusion
- B. Memory Impairment
- C. Impaired Verbal Communication
- D. Aspiration Risk
Correct Answer: D
Rationale: When identifying a priority, select the diagnosis that could be the most harmful. The nurse is most correct to select Aspiration Risk as the highest priority. Aspiration can potentially cause pneumonia. Memory Impairment and Chronic Confusion are manageable with appropriate supervision. Impaired Verbal Communication is an obstacle in expressing thoughts and feelings.
The nurse is observing the interaction between a parent and child with schizophrenia. The child states, 'The man visiting me said you went on vacation without me.' The parent replies 'There is no man, you are just making that up.' When interacting with the parent privately, which reply from the parent would the nurse suggest?
- A. I am not on vacation. I am here with you.
- B. How can I go on vacation. I do not have any money.
- C. Stop saying that. You know better. No one told you that.
- D. Just forget about that and let's talk about something else.
Correct Answer: A
Rationale: The nurse is correct to suggest not arguing with the client. This can escalate the situation. The nurse should suggest not validating the delusional belief and focus the discussion to the 'here and now.'