Nokea
The nurse is told that a patient believes he was born into the wrong body. What is the correct terminology for the desire to have the body of the opposite sex?
- A. Homosexuality
- B. Transsexualism
- C. Heterosexuality
- D. Bisexuality
Correct Answer: B
Rationale: Transsexualism is a persistent desire to be the opposite sex and to have the body of the opposite sex.
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For the past 3 weeks, the nurse has observed a patient interacting with staff and other patients, helping decorate the dining room for a party, and leading the singing in the activity room. Today, the patient tearfully refuses to dress or get out of bed. The nurse recognizes these behaviors as evidence of which psychiatric disorder?
- A. Unipolar depression
- B. Dysthymic disorder
- C. Hypomanic episode
- D. Bipolar disorder
Correct Answer: D
Rationale: Bipolar disorder can cause the patient to experience a sudden shift in emotion from one extreme to the other.
The patient is concerned about confidentiality and asks the nurse not to tell anyone what is said. What is the best response by the nurse?
- A. I am required to report any intent to hurt yourself or others.
- B. Conversations between patient and nurse are confidential.
- C. What we say can be secret. What I write in the chart is available to the health team.
- D. I can't help you unless you trust me.
Correct Answer: A
Rationale: No secrets are allowed to be kept by a member of the health care team.
The nurse is assessing a female patient who has become rapidly and exceedingly anxious because her fingernail polish is chipped. What type of anxiety should the nurse conclude that the patient is exhibiting?
- A. Signal anxiety
- B. General anxiety
- C. Anxiety traits
- D. Panic disorder
Correct Answer: C
Rationale: An individual with anxiety traits has anxious reactions to relatively nonstressful events. Signal anxiety is a learned response to an event such as test taking. An individual with general anxiety worries over many things. A panic attack occurs suddenly and typically peaks within 10 minutes.
The patient talks with his dead brother and arranges furniture so that his brother will have a place to sit. How should the nurse document this behavior?
- A. Disordered thinking
- B. Anhedonia
- C. Hallucination
- D. Alogia
Correct Answer: C
Rationale: A hallucination is a sensory experience without a stimulus trigger. Disordered thinking occurs when the individual is not able to interpret information being received in the brain. Anhedonia describes lack of expressed feelings. Alogia is reduced content of speech.
The nurse cautions a patient to watch his step. What response indicates concrete thinking?
- A. The patient fixedly begins to watch his feet.
- B. The patient immediately examines his watch.
- C. The patient begins to watch the nurse's feet.
- D. The patient stands rigidly in one place without moving.
Correct Answer: A
Rationale: Concreteness is an indication of disordered thinking. The patient is unable to translate any words except by a very concrete definition.