Nokea
Which nursing diagnosis is appropriate for a patient who insists on being called "Your Highness" and demonstrates loosely associated thoughts?
- A. Risk for violence
- B. Defensive coping
- C. Impaired memory
- D. Disturbed thought processes
Correct Answer: D
Rationale: nsisting on being called "Your Highness" and demonstrating loose associations suggests a disturbance in thought processing typical of schizophrenia.
You may also like to solve these questions
For which patient is the nurse most likely to need to schedule a pre-ECT workup and teaching?
- A. Patient A, who is newly diagnosed with dysthymic disorder
- B. Patient B, who has melancholic depression that responded well to ECT 2 years ago
- C. Patient C, who was unresponsive to a 6-week trial of SSRI antidepressant therapy
- D. Patient D, who has depression associated with diagnosis of inoperable
Correct Answer: D
Rationale: The nurse is most likely to need to schedule a pre-electroconvulsive therapy (ECT) workup and teaching for Patient D, who has depression associated with the diagnosis of an inoperable brain tumor. In such cases, ECT may be considered as a treatment option due to the severity of the depression and the limitations in using other treatments. Before ECT can be initiated in a patient with such complex medical conditions, it is crucial to conduct a thorough evaluation and preparation process, which includes obtaining informed consent, assessing the patient's medical history, conducting pre-ECT laboratory tests, and providing patient and family education about the procedure. Given the unique circumstances of Patient D's inoperable brain tumor, the nurse must ensure all necessary steps are taken to ensure the safety and efficacy of ECT as a treatment option.
Which older adult patient’s medical conditions support the hypothesis upon which the immunologic theory of aging is based?
- A. Has, at age 64, been diagnosed with type 2 diabete
- B. Has been treated for multiple sclerosis since age 30.
- C. Is managing a 36-year history of chronic Graves’ disease.
- D. Has begun to experience symptoms of rheumatoid arthritis.
Correct Answer: B, C
Rationale: he immunologic theory of aging suggests that aging is associated with increased autoimmunity. Conditions like multiple sclerosis, rheumatoid arthritis, and Graves’ disease reflect immune dysfunction.
A friend says to a nurse, “I am not going to get vaccines for my baby. I hear that vaccines cause autism.” The nurse’s best reply is:
- A. The exact cause of autism is not really known
- B. It’s believed that autism is really a result of birth trauma
- C. There is no conclusive evidence to connect autism to vaccinations.
- D. Please tell me more about where you got that information about autism?
Correct Answer: C
Rationale: This response provides factual, evidence-based information to address the common misconception linking vaccines to autism. It is clear and reassuring for the parent.
A patient returned from attending the service memorializing his wife, who died after a sudden illness. Although those around him were visibly saddened, he smiled and remained in control. He refused support from friends, stating, “I can handle anything that comes my way.” The patient’s behavior is an example of grief.
- A. Inhibited
- B. Distorted
- C. Conflicted
- D. Normal
Correct Answer: B
Rationale: The patient's behavior of smiling and remaining in control while refusing support from friends, despite attending a service memorializing his wife's death, is indicative of distorted grief. In distorted grief, individuals may show seemingly inappropriate reactions or behaviors that do not align with the typical grieving process. The patient's avoidance of accepting support and expression of excessive self-reliance in the face of a significant loss suggest a distorted way of coping with grief. In normal grief, individuals may experience a range of emotions and accept support from others as they navigate through the grieving process.
A nurse plans a staff education program for employees of a senior living community. Which topic has priority?
- A. Late-onset schizophrenia
- B. Dementia
- C. Depression and suicide
- D. Delirium
Correct Answer: C
Rationale: Depression and suicide are serious concerns for elderly individuals and should be prioritized in education for caregivers to ensure early identification and intervention.