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When coping with a patient's inappropriate expression of anger, a psychiatric-mental health nurse's initial action is to identify the:
- A. appropriate limit-setting techniques
- B. nurse's own response to the anger
- C. patient's specific defense mechanisms
- D. systems theory for effecting change
Correct Answer: B
Rationale: Understanding the nurse's own emotional response ensures objectivity and effective management of the patient's anger.
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A drug causes muscarinic receptor blockade. The nurse will assess the patient for
- A. Dry mouth.
- B. Gynecomastia.
- C. Pseudoparkinsonism.
- D. Orthostatic hypotension.
Correct Answer: A
Rationale: The correct answer is A: Dry mouth. Muscarinic receptor blockade inhibits the action of acetylcholine, leading to decreased salivary gland secretion and causing dry mouth. Gynecomastia (B) is associated with antiandrogen medications. Pseudoparkinsonism (C) is a side effect of antipsychotic medications that block dopamine receptors. Orthostatic hypotension (D) is a side effect of alpha-1 adrenergic receptor blockade.
Some eating habits that seem to contribute to the incidence of cardiovascular disease are
- A. A diet that is high in fat
- B. A diet that is low in vegetables
- C. A diet that is low in fruits
- D. All of the above
Correct Answer: D
Rationale: High-fat, low-vegetable, and low-fruit diets all contribute to cardiovascular disease by increasing cholesterol and reducing nutrients.
A 17-year-old client is admitted to the ED after being alternately hyperalert and difficult to arouse. His symptoms all started within the last few hours, during which time he became disoriented and confused. His behavior was agitated and restless, and his memory was impaired, especially for recent events. The client displayed some delusions and misinterpretations of his surroundings. The nurse knows she needs to assess the client further for:
- A. Dementia
- B. Depression
- C. Delirium
- D. Amnesia
Correct Answer: C
Rationale: The correct answer is C: Delirium. Delirium is characterized by acute and fluctuating changes in cognition, attention, and awareness. The client's sudden onset of symptoms, including disorientation, confusion, agitation, restlessness, impaired memory, delusions, and misinterpretations of surroundings, align with the hallmark features of delirium. The nurse needs to further assess the client for delirium to determine the underlying cause and provide appropriate interventions promptly.
Incorrect choices:
A: Dementia - Dementia is a chronic, progressive condition characterized by gradual cognitive decline. The client's acute onset of symptoms is not consistent with dementia.
B: Depression - Depression typically presents with persistent feelings of sadness, hopelessness, and loss of interest, which are different from the acute and fluctuating cognitive changes seen in delirium.
D: Amnesia - Amnesia refers to memory loss, which is only one aspect of the client's presentation. Delirium involves a broader range of cognitive
A newly admitted client has the diagnosis of catatonic schizophrenia. The nurse would expect to assess:
- A. Psychomotor symptoms
- B. Intense suspiciousness
- C. Inappropriate affect
- D. Clanging communication
Correct Answer: A
Rationale: Rationale:
A: Psychomotor symptoms are characteristic of catatonic schizophrenia, such as stupor or excessive motor activity.
B: Intense suspiciousness is more indicative of paranoid schizophrenia, not catatonic schizophrenia.
C: Inappropriate affect is a symptom seen in other types of schizophrenia but not specific to catatonic schizophrenia.
D: Clanging communication is associated with disorganized schizophrenia, not catatonic schizophrenia.
In catatonic schizophrenia, psychomotor symptoms like stupor, rigidity, or excitement are prominent.
Which intervention would be most appropriate for a patient with bulimia nervosa who is at risk for electrolyte imbalance?
- A. Offer the patient water or an electrolyte replacement solution.
- B. Encourage the patient to engage in regular physical activity.
- C. Administer a diuretic as prescribed by the physician.
- D. Withhold food to reduce the risk of further weight gain.
Correct Answer: A
Rationale: The correct answer is A: Offering the patient water or an electrolyte replacement solution. This intervention is appropriate because patients with bulimia nervosa are at risk for electrolyte imbalances due to purging behaviors. Providing water or electrolyte replacement solution helps to replenish lost electrolytes and maintain proper balance.
Option B is incorrect as excessive physical activity can further deplete electrolytes. Option C is inappropriate as administering a diuretic can worsen electrolyte imbalances. Option D is also incorrect as withholding food can exacerbate the patient's condition and increase the risk of electrolyte imbalances.