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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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The mother of a teen with an eating disorder tells the nurse, 'Our family is pretty well-adjusted. It's hard for me to imagine what we could have done to have this happen.' The nurse can promote more complete understanding of the etiology of eating disorders by mentioning that young women are also influenced by:
- A. The abundance of nutritious foods available.
- B. The fashion industry's idealization of thinness.
- C. Competition in the workplace.
- D. None of the above.
Correct Answer: B
Rationale: The correct answer is B: The fashion industry's idealization of thinness. This is correct because the portrayal of ultra-thin models in the fashion industry can contribute to societal pressure on young women to achieve an unrealistic body image, leading to body dissatisfaction and potentially eating disorders. The other choices are incorrect because option A does not address the societal influences on body image ideals, option C is not directly related to the etiology of eating disorders in young women, and option D is incorrect as the fashion industry can indeed play a significant role in shaping perceptions of beauty and body image.
A psychiatric technician mentions to the nurse, 'All these clients with Axis II problems! It makes me wonder how so many mothers could have been such poor parents and messed up their kids so badly!' The response by the nurse that helps put the development of personality disorders into perspective is:
- A. Parenting is the responsibility of fathers, too, so don't blame only mothers.'
- B. Personality disorder is often related to sexual abuse that occurs without parental knowledge.'
- C. There is some evidence to suggest a biologic component to personality disorders.'
- D. Peer interactions may be more important in child development than parental involvement.'
Correct Answer: C
Rationale: Step-by-step rationale for correct answer (C):
1. Personality disorders are complex and have multifactorial causes.
2. Research suggests a biological component to personality disorders, such as genetic predispositions.
3. This understanding helps to shift the blame away from solely poor parenting.
4. It aligns with the biopsychosocial model, which considers biological, psychological, and social factors.
5. This response promotes a holistic view of personality development.
Summary of why other choices are incorrect:
A: Shifts focus to gender roles, which is not directly relevant to the etiology of personality disorders.
B: Narrowly associates personality disorders with sexual abuse, ignoring other contributing factors.
D: Overemphasizes peer interactions over parental influence, which is not supported by extensive research on personality development.
A physically frail elderly patient with mild cognitive impairments needs services of a facility that can provide supervision and safety as well as recreation and social interaction. The family cares for this patient during the evening and night. Which type of facility should the nurse suggest to meet this patients needs?
- A. Adult day care program
- B. Skilled nursing facility
- C. Partial hospitalization
- D. Group home
Correct Answer: A
Rationale: A day care program provides recreation and social interaction as well as supervision in a safe environment. Nursing, medical, and rehabilitative care are usually not provided. Skilled nursing facilities go beyond meeting recreational and social needs by providing medical interventions and nursing and rehabilitation services on a 24-hour basis. Partial hospitalization provides acute psychiatric hospital programs. A group home is inappropriate and would not meet the patients needs.
A 27-year-old woman diagnosed with borderline personality disorder displays a labile affect, impulsivity, frequent angry outbursts, and difficulty tolerating her angry feelings without self-injury. A priority nursing diagnosis for this client is:
- A. Anxiety
- B. Risk for self-mutilation
- C. Risk for other-directed violence
- D. Ineffective coping
Correct Answer: B
Rationale: The correct answer is B: Risk for self-mutilation. This is the priority nursing diagnosis because the client is displaying behaviors such as self-injury due to difficulty tolerating angry feelings. Self-mutilation poses an immediate risk to the client's safety and requires immediate intervention. The other choices are incorrect because anxiety (A) is a common symptom of borderline personality disorder but not the priority in this case. Risk for other-directed violence (C) is not indicated as the client is primarily harming themselves. Ineffective coping (D) is a broad diagnosis that does not address the immediate risk of self-mutilation.
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.