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The patient on the mental health unit who should be assessed as being at highest risk for directing violent behavior toward others is the patient who has:
- A. Obsessive-compulsive disorder and performs many rituals.
- B. Paranoid delusions of being followed by the Mafia.
- C. Severe depression with feelings of worthlessness and self-loathing.
- D. Completed alcohol withdrawal and is now in a rehabilitation program.
Correct Answer: B
Rationale: The correct answer is B because paranoid delusions of being followed by the Mafia indicate a high level of suspiciousness and potential for harm to others. This patient may act out violently in self-defense or as a reaction to perceived threats. Choice A is incorrect as OCD rituals are typically not associated with violent behavior. Choice C is incorrect as severe depression is more likely to result in self-harm rather than harm towards others. Choice D is incorrect as completed alcohol withdrawal and entering a rehabilitation program do not inherently indicate an increased risk of violent behavior towards others.
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The nurse working with a client whose diagnosis is bulimia asks the client to recall a time in her life when eating was a positive experience and she enjoyed small amounts of food without purging. The purpose of this intervention is to:
- A. gain additional information about the client's bulimic condition.
- B. emphasize that the client is capable of engaging in eating without purging.
- C. incorporate specific foods into the meal plan to reflect pleasant memories.
- D. assist the client to become more compliant with the treatment plan.
Correct Answer: B
Rationale: The correct answer, B, emphasizes that the client is capable of engaging in eating without purging. By asking the client to recall a positive experience with food, the nurse is helping the client recognize that they can enjoy food without the need to purge. This intervention aims to challenge the client's negative beliefs about food and eating, promoting a healthier relationship with food.
Choice A is incorrect as the purpose is not solely to gain additional information about the client's condition but rather to shift the client's perspective on food. Choice C is incorrect as the intervention focuses on emotional aspects rather than specific foods. Choice D is incorrect as the goal is to address the psychological aspect of the client's behavior, not just compliance with the treatment plan.
A nursing diagnosis for a patient with bulimia nervosa is Ineffective coping related to feelings of loneliness and isolation, as evidenced by use of overeating and self-induced vomiting to comfort self. Select the best outcome related to this diagnosis. Within 2 weeks, the patient will:
- A. Appropriately express angry feelings.
- B. Verbalize two positive things about self.
- C. Verbalize the importance of eating a balanced diet.
- D. None of the above.
Correct Answer: D
Rationale: Rationale:
1. Patient's diagnosis indicates coping issues, not anger expression or self-esteem.
2. Patient's coping mechanism involves overeating and vomiting, not diet.
3. Outcome should focus on coping skills improvement, not unrelated goals.
4. None of the choices address the root issue of coping with loneliness and isolation.
5. Thus, the correct answer is D, as none of the options directly address the patient's ineffective coping mechanism.
The severe feeling of restlessness produced by some psychotropic medications, which is often misinterpreted by patients as anxiety or a recurrence of psychiatric symptoms, is known as:
- A. akathisia
- B. akinesia
- C. bradykinesia
- D. dystonia
Correct Answer: A
Rationale: Akathisia is a common side effect of antipsychotics, characterized by restlessness often mistaken for worsening psychiatric symptoms.
A health care provider writes these new prescriptions for a resident in a skilled nursing facility: 2G sodium diet, Restraint as needed, Limit fluids to 1800~mL daily, Continue antihypertensive medication, Milk of magnesia 30~mL PO once if no bowel movement for 3 days. The nurse should:
- A. question the fluid restriction
- B. question the order for restraint
- C. transcribe the prescriptions as written
- D. assess the residents bowel elimination
Correct Answer: B
Rationale: Restraints may be imposed only on a written order of the health care provider that specifies the duration during which the restraints can be used. The Joint Commission guidelines and Omnibus Budget Reconciliation Act regulations also mandate a number of other conditions that must be considered and documented before restraints are used. The other prescriptions are appropriate.
The client tells the nurse, 'I thought my psychiatrist was the best doctor in the world. I thought he understood me completely. Now, I hate him! He doesn't understand me at all. He's just dumping me to go on a 2-week vacation.' The nurse assesses the client's description of feelings about the physician as evidence of the use of:
- A. Splitting
- B. Projective identification
- C. Isolation of affect
- D. Dissociation
Correct Answer: A
Rationale: The correct answer is A: Splitting. Splitting is a defense mechanism where a person sees things in extremes of either all good or all bad. In this scenario, the client initially idealizes the psychiatrist as the best doctor, then suddenly devalues and hates him for taking a vacation, indicating a shift from all good to all bad. This extreme change in perception is characteristic of splitting.
B: Projective identification involves projecting one's own feelings onto another person and then identifying with those projected feelings. This choice does not fit the scenario as the client is not projecting their feelings onto the psychiatrist.
C: Isolation of affect refers to the separation of feelings from ideas and events. The client's strong emotions towards the psychiatrist do not demonstrate a lack of emotional expression or detachment from feelings.
D: Dissociation is a defense mechanism where thoughts, feelings, and experiences are separated from conscious awareness. The client's reaction does not suggest a disconnection from reality or consciousness.