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When a patient is diagnosed with major depressive disorder, which nursing diagnosis should be the priority?
- A. Imbalanced nutrition: less than body requirements
- B. Risk for suicide
- C. Disturbed sleep pattern
- D. Ineffective coping
Correct Answer: B
Rationale: The correct answer is B: Risk for suicide. This is the priority nursing diagnosis because individuals with major depressive disorder have an increased risk of suicidal ideation and behaviors. Assessing and addressing this risk is crucial for patient safety. Choice A is not the priority as nutritional imbalances may not pose immediate harm compared to suicide risk. Choice C, disturbed sleep pattern, and choice D, ineffective coping, are important but not as critical as addressing the risk of suicide in a patient with major depressive disorder.
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In schizophrenia, a patient is experiencing negative symptoms. Which of the following is a negative symptom?
- A. Hallucinations
- B. Delusions
- C. Apathy
- D. Disorganized speech
Correct Answer: C
Rationale: The correct answer is C: Apathy. Negative symptoms in schizophrenia refer to the absence or reduction of normal behaviors or functions. Apathy is a common negative symptom characterized by a lack of interest, motivation, or emotion. Hallucinations (A) and delusions (B) are positive symptoms, involving distortions of perception or belief. Disorganized speech (D) is a symptom of disorganized thinking, which is also a positive symptom in schizophrenia. Thus, apathy best aligns with the concept of negative symptoms in schizophrenia.
When a patient with schizophrenia is taking haloperidol, what is a priority assessment for the nurse?
- A. Assessing for signs of tardive dyskinesia
- B. Monitoring for signs of neuroleptic malignant syndrome
- C. Checking for signs of depression
- D. Monitoring for changes in appetite
Correct Answer: B
Rationale: The correct answer is B: Monitoring for signs of neuroleptic malignant syndrome. This is because neuroleptic malignant syndrome is a potentially life-threatening side effect of haloperidol, characterized by fever, muscle rigidity, altered mental status, and autonomic dysfunction. It requires immediate medical intervention. Assessing for tardive dyskinesia (A) is important but not as urgent as monitoring for neuroleptic malignant syndrome. Checking for signs of depression (C) is relevant but not a priority when the patient is at risk of a serious adverse reaction. Monitoring changes in appetite (D) is less critical than assessing for neuroleptic malignant syndrome, as it is a common side effect that does not pose an immediate threat to the patient's life.
A patient with generalized anxiety disorder is being taught about buspirone. Which statement indicates the patient needs further teaching?
- A. I should take this medication consistently rather than on an as-needed basis.
- B. It may take a few weeks to feel the full effect of this medication.
- C. This medication has a lower risk of dependency compared to benzodiazepines.
- D. I should avoid drinking alcohol while taking this medication.
Correct Answer: A
Rationale: Step-by-step rationale:
1. Buspirone is not meant for immediate relief, so taking it consistently is crucial for its effectiveness.
2. Buspirone takes time to build up in the body and show its full effect, usually a few weeks.
3. Buspirone is known for having a lower risk of dependency compared to benzodiazepines.
4. Taking buspirone consistently is essential, unlike benzodiazepines which are often taken on an as-needed basis.
Therefore, choice A is incorrect as it goes against the appropriate usage of buspirone for treating generalized anxiety disorder.
Which of the following is a common symptom of borderline personality disorder?
- A. Obsessive-compulsive behaviors
- B. Fear of social situations
- C. Grandiose sense of self-importance
- D. Impulsive and self-destructive behaviors
Correct Answer: D
Rationale: The correct answer is D: Impulsive and self-destructive behaviors. This is a common symptom of borderline personality disorder as individuals often engage in reckless behaviors without considering the consequences. They may have self-harming tendencies and engage in impulsive actions like substance abuse or risky sexual behavior.
A: Obsessive-compulsive behaviors are more characteristic of obsessive-compulsive disorder, not borderline personality disorder.
B: Fear of social situations is more indicative of social anxiety disorder, not borderline personality disorder.
C: Grandiose sense of self-importance is a symptom of narcissistic personality disorder, not borderline personality disorder.
In summary, impulsive and self-destructive behaviors are key features of borderline personality disorder, distinguishing it from other mental health conditions.
When developing a care plan for a patient with borderline personality disorder, which intervention should be included to address self-harm behaviors?
- A. Encouraging the patient to keep a journal of their thoughts and feelings.
- B. Setting clear and consistent boundaries with the patient.
- C. Providing the patient with coping skills to manage their emotions.
- D. Developing a safety plan with the patient.
Correct Answer: D
Rationale: The correct answer is D, developing a safety plan with the patient. This intervention is crucial for addressing self-harm behaviors in patients with borderline personality disorder. A safety plan helps the patient identify triggers, warning signs, coping strategies, and support networks to prevent self-harm. It also outlines specific steps to take in a crisis situation. This intervention is more direct and practical compared to the other options.
A: Keeping a journal may be helpful for self-reflection but may not provide immediate strategies to prevent self-harm.
B: Setting boundaries is important but may not directly address self-harm behaviors.
C: Providing coping skills is beneficial, but a safety plan is more specific and tailored to managing self-harm risks.
In summary, developing a safety plan is the most effective intervention for addressing self-harm behaviors in patients with borderline personality disorder.