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The nurse reports to the interdisciplinary team that an antisocial patient lies to other patients, verbally abuses a patient with Alzheimer's disease, flatters his primary nurse, and is detached and superficial during counseling sessions. Which behavior should be the priority focus of limit setting?
- A. Lying to other patients
- B. Flattering the nursing staff
- C. Verbally abusing other patients
- D. Superficiality during counseling
Correct Answer: C
Rationale: The correct answer is C: Verbally abusing other patients should be the priority focus of limit setting. This behavior poses a direct threat to the safety and well-being of other patients. By addressing verbal abuse first, the nurse can establish boundaries and maintain a safe environment for all patients. Lying to other patients (A) may be addressed but is not as immediate a concern. Flattering the nursing staff (B) is manipulative but not as harmful as verbal abuse. Superficiality during counseling sessions (D) may indicate other issues but is not as urgent as addressing the verbal abuse.
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Bob has never met Madonna but he is convinced that she is deeply in love with him. Bob is suffering from
- A. grandiose delusions
- B. jealous delusions
- C. obsessive-compulsive disorder
- D. erotomanic delusions
Correct Answer: A
Rationale: This should be D (erotomanic delusions), where a person believes someone, often a celebrity, is in love with them; the answer key may be incorrect as grandiose delusions involve exaggerated self-importance.
When a patient diagnosed with paranoid schizophrenia was discharged from the unit 6 months ago, the plan was for him to take chlorpromazine (Thorazine), a conventional (first generation) antipsychotic medication, 300 mg po daily. He tells the nurse he stopped taking his pills after a few months because they made him feel like a 'zombie.' What other common side effects should the nurse determine if the patient experienced?
- A. Sweating, nausea, and weight gain
- B. Sedation, tremor, and muscle stiffness
- C. Headache, watery eyes, and runny nose
- D. Mild fever, sore throat, and skin rash
Correct Answer: B
Rationale: The correct answer is B: Sedation, tremor, and muscle stiffness. This is because chlorpromazine, being a first-generation antipsychotic, commonly causes sedation, tremors, and muscle stiffness as side effects. Sedation is a common effect due to the drug's ability to block dopamine receptors in the brain. Tremors and muscle stiffness are also common due to the drug's action on the central nervous system. Choices A, C, and D are incorrect as they do not align with the expected side effects of chlorpromazine. Sweating, nausea, weight gain, headache, watery eyes, runny nose, mild fever, sore throat, and skin rash are not typically associated with this medication.
A new nurse asks, 'My elderly patient's CT scan of the head shows many Lewy bodies are present. What should I do about assessing for pain?' Select the best response from the nurse manager.
- A. Ask the patient's family if they think the patient is experiencing pain.
- B. Use a visual analog scale to help the patient determine the presence and severity of pain.
- C. There are special scales for assessing patients with dementia. Let's review how to use them.
- D. The perception of pain is diminished by this type of dementia. Focus your assessment on the patient's mental status.
Correct Answer: C
Rationale: The correct answer is C because patients with Lewy body dementia may have difficulty expressing pain. Special pain assessment scales designed for patients with dementia can help in accurately assessing pain levels. These scales take into account nonverbal cues and behavioral changes that may indicate pain. By using these specialized tools, the nurse can ensure a more comprehensive assessment of the patient's pain experience.
Choice A is incorrect because relying solely on family members' perceptions may not accurately reflect the patient's actual pain experience.
Choice B is not the best option because a visual analog scale may not be suitable for patients with dementia who may have cognitive impairments affecting their ability to use such tools effectively.
Choice D is incorrect as it assumes that pain perception is diminished in Lewy body dementia without considering that patients may still experience pain but have difficulty communicating it. Focusing solely on mental status may overlook important pain indicators.
The nurse is assessing a patient with anorexia nervosa. What is the most important physical examination finding to monitor?
- A. Blood pressure and heart rate.
- B. Height and weight changes.
- C. Skin turgor and hydration status.
- D. Respiratory rate and lung function.
Correct Answer: B
Rationale: The correct answer is B: Height and weight changes. In anorexia nervosa, monitoring height and weight changes is crucial as it reflects the patient's nutritional status and overall health. Weight loss and changes in height can indicate severe malnutrition and potential complications. Blood pressure and heart rate (choice A) can be affected by various factors in anorexia nervosa but may not directly reflect the patient's nutritional status. Skin turgor and hydration status (choice C) are important indicators of hydration levels but may not provide a comprehensive assessment of the patient's nutritional status. Respiratory rate and lung function (choice D) are important, but they may not be the most critical physical examination findings to monitor in anorexia nervosa.
What should the nurse do when a patient with anorexia nervosa expresses a fear of gaining weight?
- A. Minimize the patient's fears to avoid anxiety.
- B. Provide information about the importance of weight gain for health.
- C. Encourage weight loss to help the patient feel more in control.
- D. Agree with the patient's concerns and avoid discussing the topic.
Correct Answer: B
Rationale: The correct answer is B because providing information about the importance of weight gain for health helps educate the patient on the risks of anorexia nervosa. By doing so, the nurse can address the patient's fears in a supportive and informative manner, promoting a better understanding of the need for weight gain.
Choice A is incorrect because minimizing the patient's fears may invalidate their feelings and hinder therapeutic communication. Choice C is incorrect as encouraging weight loss can exacerbate the patient's condition and reinforce unhealthy behaviors. Choice D is incorrect because agreeing with the patient's concerns perpetuates the harmful beliefs associated with anorexia nervosa.