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What environmental conditions should the nurse arrange for a patient with delirium and altered perceptions of their environment?
- A. Provide a quiet, well-lit room without glare or shadows.
- B. Have the patient sit by the nurse's desk while awake.
- C. Reduce room lighting to minimize overstimulation.
- D. None of the above.
Correct Answer: A
Rationale: The correct answer is A because a quiet, well-lit room without glare or shadows helps reduce environmental stimuli that can exacerbate delirium and altered perceptions. This environment promotes calmness and clarity for the patient. Choice B is incorrect as it may increase distractions and stimuli. Choice C may lead to inadequate lighting that can worsen confusion. Choice D is incorrect as environmental modifications are crucial for managing delirium.
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Suicidal tendency is most commonly seen with
- A. Schizophrenia
- B. Obsessive Disorders
- C. Mania
- D. Depression
Correct Answer: D
Rationale: Depression is the most common mental disorder associated with suicidal tendencies due to persistent feelings of hopelessness and despair.
A short-term goal for a patient with Alzheimer disease is:
- A. Improved functioning in the least restrictive environment
- B. improved problem solving in activities of daily living
- C. increased self-esteem and improved self-concept
- D. regained sensory perception and cognitive function
Correct Answer: A
Rationale: Promoting function in a safe, least restrictive setting is realistic and achievable given Alzheimer's progressive nature.
A nurse is caring for a patient with bulimia nervosa. What is a priority assessment for this patient?
- A. Electrolyte imbalances and cardiac function.
- B. Body image issues and mental health status.
- C. Nutritional status and hydration levels.
- D. Weight changes and exercise patterns.
Correct Answer: A
Rationale: The correct answer is A: Electrolyte imbalances and cardiac function. This is because patients with bulimia nervosa often engage in purging behaviors which can lead to electrolyte imbalances and cardiac complications. Assessing electrolyte levels and cardiac function is crucial to prevent life-threatening complications.
Choice B is incorrect because while body image and mental health are important considerations, they are not the priority assessment in this case. Choice C is also incorrect as nutritional status and hydration levels can be affected, but not as immediately life-threatening as electrolyte imbalances and cardiac issues. Choice D is incorrect as weight changes and exercise patterns may be important, but they are not the priority assessment for a patient with bulimia nervosa.
An outpatient diagnosed with schizophrenia attends programming at a community mental health center. The patient says, I threw away the pills because they keep me from hearing God. Which response by the nurse would most likely to benefit this patient?
- A. You need your medicine. Your schizophrenia will get worse without it.
- B. Do you want to be hospitalized again? You must take your medication.
- C. I would like you to come to the medication education group every Thursday.
- D. I noticed that when you take the medicine, you have been able to hold a job you wanted.
Correct Answer: D
Rationale: Connecting medication to the patient's goal (job) (D) motivates adherence despite desirable hallucinations. Exhortations (A, B) ignore insight issues, and education (C) assumes a knowledge deficit, not the core problem.
Inappropriate, life-threatening or challenging behaviours may be inadvertently maintained by reinforcement from others in the environment. Which of the following is a process that can be carried out in order to help identify the factors maintaining the behaviour?
- A. Functional analysis
- B. Statistical analysis
- C. Behavioural analysis
- D. Procedural analysis
Correct Answer: A
Rationale: Functional Analysis: Using operant conditioning principles to identify rewarding or reinforcing factors maintaining behavior.