Nokea
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.
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The home health nurse assesses a patient who creates elaborate excuses for not leaving home. Further questioning reveals the patient had not left home for 6 months. How should this be documented?
- A. Mania
- B. Depression
- C. Agoraphobia
- D. Anxiety
Correct Answer: C
Rationale: Agoraphobia is a high level of anxiety in which an anxiety attack could occur in individuals who avoid other people, places, or events.
The nurse is caring for a patient with a diagnosis of catatonic schizophrenia. What behavior is consistent with this diagnosis?
- A. Talks excitedly about going home.
- B. Suspiciously watches the staff.
- C. Stands on one foot for 15 minutes.
- D. States he has a cat under his bed that talks to him.
Correct Answer: C
Rationale: Maintaining a rigid pose for long periods of time is an example of behavior expected with catatonic schizophrenia.
A profound, disabling mental illness is characterized by bizarre, nonreality thinking. What is the illness?
- A. Manic depressive
- B. Schizophrenia
- C. Paranoia
- D. Bipolar
Correct Answer: B
Rationale: Schizophrenia, a thought process disorder, is one of the most profoundly disabling mental illnesses.
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.
The nurse asks a patient with schizophrenia if he had any visitors on Sunday. Which response indicates loose association?
- A. No.
- B. Yes! I had 90 visitors who came from every state in the union.
- C. Sunday is the Sabbath. Do we have visitors on the Sabbath?
- D. We visited Yellowstone Park last summer.
Correct Answer: D
Rationale: Loose association is a type of disordered thinking that occurs when the individual cannot interpret information and the conversation does not flow.