Nokea
Which neurological deficit(s) would the nurse be most likely to encounter when assessing a patient diagnosed with schizophrenia?
- A. Weakness and loss of function
- B. Droopy eyelids with reddened cornea
- C. Paralysis and diminished reflexes
- D. Increased blinking and impaired fine motor skills
Correct Answer: D
Rationale: The correct answer is D because in schizophrenia, patients may exhibit increased blinking and impaired fine motor skills due to medication side effects or neurological changes. Weakness, loss of function, droopy eyelids with reddened cornea, paralysis, and diminished reflexes are not commonly associated with schizophrenia. It is crucial for the nurse to recognize these neurological deficits to provide appropriate care and support for the patient.
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Which nursing diagnosis is most appropriate for a patient with bulimia nervosa who engages in frequent purging behaviors?
- A. Ineffective coping related to inability to control impulses.
- B. Risk for injury related to electrolyte imbalances.
- C. Imbalanced nutrition: less than body requirements related to food refusal.
- D. Disturbed body image related to fear of weight gain.
Correct Answer: B
Rationale: The correct answer is B: Risk for injury related to electrolyte imbalances. Patients with bulimia nervosa who engage in frequent purging behaviors are at risk for electrolyte imbalances due to loss of potassium, sodium, and other essential minerals. This can lead to serious complications such as cardiac arrhythmias and organ damage. Monitoring and addressing electrolyte imbalances is crucial in the care of these patients to prevent potential harm.
A: Ineffective coping related to inability to control impulses is not the most appropriate diagnosis as it does not directly address the immediate risk of electrolyte imbalances in this scenario.
C: Imbalanced nutrition: less than body requirements related to food refusal is not the most appropriate diagnosis as the primary concern in bulimia nervosa with purging behaviors is the risk of electrolyte imbalances, not necessarily inadequate food intake.
D: Disturbed body image related to fear of weight gain is not the most appropriate diagnosis as it does not address the immediate physical health risks
The nurse has been working with a patient diagnosed with schizophrenia who experiences auditory hallucinations. The patient relates, 'When I first heard the voices they said nice things about me. Lately, they've changed and they say bad things.' What information has the least impact on therapeutic patient care at this point in the hospitalization?
- A. Do you trust me to help you with the voices?'
- B. Are the voices commanding you to do something?'
- C. How often during 24 hours do you hear the voices?'
- D. Do you hear the voices if you're busy in noisy environment?'
Correct Answer: A
Rationale: Rationale for Correct Answer (A): Asking the patient if they trust the nurse to help with the voices is the least impactful at this point because establishing trust should have already been a priority earlier in the hospitalization. The focus now should be on assessing the nature and frequency of the auditory hallucinations to guide further treatment and intervention.
Summary of Incorrect Choices:
B: This question is important to assess if the voices are commanding potentially harmful actions.
C: Understanding the frequency of the voices is crucial in evaluating the severity of the symptoms.
D: Inquiring about hearing voices in different environments helps assess the impact of external factors on the hallucinations.
When making a distinction as to whether an elderly patient has confusion related to delirium or another problem, what information would be of particular value?
- A. Evidence of spasticity or flaccidity
- B. The patient's level of motor activity
- C. Medications the patient has recently taken
- D. Level of preoccupation with somatic symptoms
Correct Answer: C
Rationale: The correct answer is C: Medications the patient has recently taken. This information is crucial because certain medications can cause delirium in elderly patients. By reviewing the patient's recent medications, healthcare providers can identify potential drug-induced delirium and adjust treatment accordingly. Spasticity or flaccidity (choice A) is more indicative of neurologic conditions, not delirium. The patient's level of motor activity (choice B) may provide some insight but is not as specific to delirium as medication history. The level of preoccupation with somatic symptoms (choice D) is more relevant to other psychiatric conditions and does not directly help in distinguishing delirium.
Which nursing intervention will assist a client being treated in the Emergency Department for extensive soft tissue injuries to disclose an experience of domestic violence?
- A. Interviewing her in the presence of another professional
- B. Speaking with the client in the absence of her husband
- C. Providing a safe, nonintimidating environment
- D. Allowing the client to initiate the topic of violence
Correct Answer: C
Rationale: Rationale for Correct Answer (C): Providing a safe, nonintimidating environment is crucial to encourage the client to disclose domestic violence. This approach helps establish trust and confidentiality, making the client feel secure to share sensitive information. It creates a conducive setting for open communication without fear of repercussions.
Summary of Incorrect Choices:
A: Interviewing her in the presence of another professional may not ensure privacy and could potentially increase the client's discomfort or fear of being overheard.
B: Speaking with the client in the absence of her husband might not guarantee safety and confidentiality, as the client may still feel threatened or hesitant to reveal the abuse.
D: Allowing the client to initiate the topic of violence puts the burden on the client, who may already be feeling overwhelmed or unable to bring up the sensitive issue without support and encouragement.
A community mental health nurse is assigned to investigate the frequent school absences of an 11-year-old child. The nurse finds the child home alone, caring for his 1- and 3-year-old siblings. The house is cluttered and dirty, and both parents are at work. The child tells the nurse that whenever his mother is called to work at her part-time job, he must watch the kids because the family cannot afford a babysitter. Based on the information obtained thus far, what preliminary assessment can be made?
- A. The child is coping well with a difficult situation.
- B. The child and his siblings are experiencing neglect.
- C. The children are at high risk for sexual abuse.
- D. The children are experiencing physical abuse.
Correct Answer: B
Rationale: The correct answer is B: The child and his siblings are experiencing neglect. Neglect is defined as failure to provide for a child's basic needs, such as supervision, food, shelter, and medical care. In this scenario, the child is left alone to care for his younger siblings, indicating a lack of appropriate supervision and care from the parents. The house being cluttered and dirty further suggests neglect in terms of living conditions.
Choice A is incorrect because the child is not coping well; rather, he is forced into a caretaker role beyond his developmental capacity. Choice C is incorrect as there is no information provided to suggest sexual abuse. Choice D is incorrect as there is no evidence of physical abuse in the scenario.