Nokea
The nurse who is caring for a 23-year-old client with bulimia knows that the most common method of purging to monitor this client for is:
- A. Vomiting.
- B. Starvation.
- C. Excessive enema use.
- D. None of the above.
Correct Answer: A
Rationale: The correct answer is A: Vomiting. In bulimia, vomiting is the most common method of purging after binge eating to control weight. Monitoring for signs of vomiting, such as frequent trips to the bathroom after meals or presence of swollen salivary glands, is crucial. Starvation (B) is not a method of purging in bulimia but rather a consequence of restriction in anorexia nervosa. Excessive enema use (C) is not a common method of purging in bulimia and can be harmful. Therefore, the correct choice is A as it aligns with the typical behavior of individuals with bulimia.
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Here in Boston our water comes from
- A. Groundwater
- B. The Charles River
- C. Marlborough
- D. The Quabbin Reservoir
Correct Answer: D
Rationale: Boston's primary water source is the Quabbin Reservoir, which supplies clean water to the metropolitan area.
A patient who has been hospitalized for 2 days remains delusional and anxious and does not yet appear to be ready to give up the delusions. What intervention will best help the patient focus less on the delusion?
- A. Schedule time for the patient to read and listen to music.
- B. Plan activities that require physical skills and constructive use of time.
- C. Begin planning for discharge by engaging the patient in psychoeducation.
- D. Discuss personal goals related to improved socialization with the patient.
Correct Answer: B
Rationale: The correct answer is B because engaging in activities that require physical skills and constructive use of time can help the patient shift their focus away from the delusions. Physical activities can help reduce anxiety and provide a sense of accomplishment, which can help distract the patient from the delusions. It also promotes a sense of normalcy and routine, which can aid in grounding the patient in reality.
Choice A is incorrect because reading and listening to music may not actively engage the patient in a way that helps them shift their focus from the delusions. Choice C is incorrect because planning for discharge may be premature and may not address the immediate need to distract the patient from the delusions. Choice D is incorrect because discussing personal goals related to improved socialization may not be effective in helping the patient focus less on the delusions at this stage.
A client who has been diagnosed as having paranoid schizophrenia is highly suspicious and delusional. He hears voices telling him terrorists are plotting to assassinate him. He refuses to eat, saying the food is poisoned. The nursing action that best addresses his needs is to:
- A. Explain that others eat the food and are not harmed
- B. Allow client to select food from vending machines
- C. Assist client with personal hygiene and grooming
- D. Not allow client to verbalize delusional thoughts
Correct Answer: B
Rationale: The correct answer is B: Allow client to select food from vending machines. This option respects the client's autonomy and addresses his specific delusion of food being poisoned. By allowing the client to select food from vending machines, he can choose items he believes are safe, which can help alleviate his paranoia and increase his trust in the care being provided. This approach promotes a therapeutic relationship and empowers the client in making choices about his care.
Explanation of why other choices are incorrect:
A: Explaining that others eat the food and are not harmed may not be effective as the client's delusion is strong, and rational arguments may not be helpful in this case.
C: Assisting with personal hygiene and grooming is important but does not directly address the client's delusion about food being poisoned.
D: Not allowing the client to verbalize delusional thoughts can escalate the client's distress and hinder the therapeutic relationship. It is essential to acknowledge the client's experiences and work towards building trust and rapport
A patient with schizophrenia refuses to take his medication because he believes he is not ill. What phenomenon most likely underlies this presentation?
- A. The patient is unable to face having an illness and is in denial.
- B. Stigma causes the patient to refuse to admit his mental illness.
- C. The illness itself is preventing the patient from realizing he is ill.
- D. Command hallucinations are instructing him to deny the illness.
Correct Answer: C
Rationale: The correct answer is C because anosognosia, a symptom of schizophrenia, can prevent patients from recognizing they are ill due to the illness itself affecting their insight and awareness. Anosognosia is a neurocognitive deficit common in schizophrenia, where the brain's ability to recognize one's own illness is impaired. This leads the patient to genuinely believe they are not ill, even when presented with evidence to the contrary.
Choice A: Denial is a psychological defense mechanism, not a symptom of schizophrenia.
Choice B: Stigma might influence perceptions of mental illness, but it does not directly cause anosognosia in schizophrenia.
Choice D: Command hallucinations can influence behavior, but they typically involve auditory commands unrelated to recognizing one's illness.
Features of schizoid personality include.
- A. Hyper-vigilant ready for real or imagines threat
- B. Inability to respond to others, hyper-vigilant
- C. Social withdrawal, inability to respond to others
- D. Ready for real or imagined threat, social withdrawal
Correct Answer: C
Rationale: Schizoid personality disorder is characterized by social withdrawal and emotional detachment, with little interest in relationships.