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Which of the following interventions should the nurse plan to use to reduce client focus on delusional thinking?
- A. Confronting the delusion
- B. Focusing on feelings suggested by the delusion
- C. Refuting the delusion with logic
- D. Exploring reasons the client has the delusion
Correct Answer: B
Rationale: The correct answer is B: Focusing on feelings suggested by the delusion. By addressing the underlying emotions associated with the delusion, the nurse can help the client process and cope with their feelings, ultimately reducing the intensity of the delusional thinking. Confronting the delusion (A) may lead to resistance and escalation. Refuting the delusion with logic (C) can be ineffective as it may reinforce the client's belief. Exploring reasons for the delusion (D) may not directly address the client's focus on delusional thinking.
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In a sad voice, an elderly patient tells the nurse of the recent deaths of a spouse and close friend. The patient has no other family and only a few acquaintances in the community. The nurse's priority is to determine whether which nursing diagnosis applies to this patient?
- A. Risk for suicide related to recent deaths of significant others
- B. Anxiety related to sudden and abrupt lifestyle changes
- C. Social isolation related to loss of existing family
- D. Spiritual distress related to anger with God
Correct Answer: A
Rationale: The correct answer is A: Risk for suicide related to recent deaths of significant others. This is the priority because the patient's recent losses put them at high risk for suicide. The nurse must assess the patient's risk level and provide appropriate interventions to prevent harm. Choices B, C, and D are incorrect because anxiety and social isolation are secondary concerns compared to the immediate risk of suicide. Spiritual distress, while important, does not take precedence over the patient's safety.
A person diagnosed with a serious mental illness enters a shelter for the homeless. Which intervention should be the nurses initial priority?
- A. Find supported employment
- B. Develop a trusting relationship
- C. Administer prescribed medication
- D. Teach appropriate health care practices
Correct Answer: B
Rationale: Basic psychosocial needs do not change because a person is homeless. The first step in caring for health care needs is establishing rapport. Once a trusting relationship is established, the nurse pursues other interventions.
A patient with an eating disorder states, 'I heard people laughing behind me in the check-out line at the department store. I bet they thought it was hysterically funny that I gained a pound in the last few days.' The nurse documents that the patient is exhibiting which cognitive distortion related to maladaptive eating regulation responses?
- A. Magnification
- B. Personalization
- C. Overgeneralization
- D. Dichotomous thinking
Correct Answer: B
Rationale: The correct answer is B: Personalization. Personalization is a cognitive distortion where an individual attributes external events to themselves without any evidence. In this case, the patient is assuming that people laughing were directed at them and related to their weight gain, which is a distorted belief.
A: Magnification involves blowing things out of proportion, which is not evident in this scenario.
C: Overgeneralization involves drawing broad conclusions based on a single incident, which is not happening here.
D: Dichotomous thinking involves seeing things in black and white terms, which is not demonstrated in the patient's statement.
In summary, the patient's attribution of others' laughter to their weight gain without evidence aligns with the cognitive distortion of personalization, making it the correct choice.
A patient diagnosed with schizophrenia has difficulty completing tasks and seems forgetful and disinterested in unit activities. A nurse can best select successful strategies by understanding that these behaviors are due to:
- A. a lack of self-esteem.
- B. manipulative tendencies.
- C. shyness and embarrassment.
- D. problems in cognitive functioning.
Correct Answer: D
Rationale: The correct answer is D: problems in cognitive functioning. In schizophrenia, cognitive deficits are common, leading to difficulties in completing tasks, forgetfulness, and lack of interest. Understanding this helps the nurse select appropriate strategies, such as breaking tasks into smaller steps. Choice A (lack of self-esteem) is incorrect as cognitive deficits in schizophrenia are not solely related to self-esteem. Choice B (manipulative tendencies) is incorrect as these behaviors are not indicative of manipulation. Choice C (shyness and embarrassment) is incorrect as cognitive deficits in schizophrenia go beyond social anxiety.
A patient has a maladaptive response to eating regulation. Findings include the following: height, 5 feet 3 inches; current weight, 80 pounds with weight loss of 30% of body weight over the past 3 months; T, 96.6m F; BP, 68/40; P, 40; R, 20; poor skin turgor; lanugo; amenorrhea of 6 months' duration; admits to restricting intake to 350 calories daily; is a vegetarian; dissatisfied with eating pattern as evidenced by patient statement, 'I need to lose another 10 pounds to be at ideal weight'; diagnostic testing reveals serum potassium of 2.9 mEq/L and urine specific gravity of 1.028. Which of the following would be the highest priority nursing diagnosis for this patient?
- A. Imbalanced nutrition, less than body requirements.
- B. Disturbed body image.
- C. Deficient fluid volume.
- D. Powerlessness.
Correct Answer: C
Rationale: The correct answer is C: Deficient fluid volume. The patient is displaying signs of severe malnutrition and dehydration, as evidenced by significant weight loss, low blood pressure, low heart rate, and poor skin turgor. The low serum potassium and high urine specific gravity indicate dehydration. Addressing fluid volume deficiency is the top priority to stabilize the patient's condition and prevent further complications like electrolyte imbalances and organ damage. Choices A and B are important but secondary to addressing the immediate threat of dehydration. Choice D is not the priority as the patient's primary concern is physiological rather than psychological.