Nokea
Which of the following is not a common characteristic of oppositional behaviour?
- A. Saying no to requests
- B. Accepting responsibility for mistakes
- C. Unwilling to accept changes to routines or environments
- D. Refusing to follow instructions
Correct Answer: B
Rationale: Accepting responsibility for mistakes is not typical of oppositional behavior, which often involves defiance and blame-shifting.
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The expected outcome for a patient with a nursing diagnosis of disturbed thought processes is:
- A. The patient will be safe from injury.
- B. The patient will meet basic biological needs.
- C. The patient will achieve optimum cognitive functioning.
- D. The patient will maintain positive interpersonal relationships.
Correct Answer: C
Rationale: The correct answer is C because disturbed thought processes indicate cognitive impairment. Thus, the expected outcome should focus on improving cognitive functioning to achieve optimal mental clarity and decision-making. Safety (A) is important but not directly related to cognitive improvement. Meeting basic needs (B) and maintaining relationships (D) are important but not the primary focus when the diagnosis is disturbed thought processes. So, the priority is on enhancing cognitive functioning to address the root cause of the issue.
A patient with swelling and a laceration above the right eye states, 'I don't know what caused me to fall and cut my head on the door frame in my bedroom. I'm lucky my spouse was home to take me to the hospital.' The patient's spouse appears nervous but smiles when mentioning that the patient is 'so clumsy at times.' Which nursing intervention should the nurse give priority attention to when addressing this patient's needs?
- A. Provide a thorough assessment that includes a focus on signs of old injuries.
- B. Interview the patient regarding the circumstances surrounding this suspicious fall.
- C. Directly ask the patient if spousal abuse is occurring or has ever occurred.
- D. Notify security that there is a possibility that this patient is a victim of physical abuse.
Correct Answer: A
Rationale: The correct answer is A: Provide a thorough assessment that includes a focus on signs of old injuries. This is the priority intervention because the patient's statement, combined with the spouse's behavior, raises suspicion of potential domestic abuse. By assessing for signs of old injuries, the nurse can gather crucial information to determine if the patient is a victim of abuse.
Choice B: Interview the patient regarding the circumstances surrounding this suspicious fall may be important, but assessing for signs of old injuries takes priority as it provides concrete evidence of potential abuse.
Choice C: Directly ask the patient if spousal abuse is occurring or has ever occurred is necessary, but the patient may not feel comfortable disclosing abuse directly. Assessing for old injuries can provide objective evidence.
Choice D: Notify security that there is a possibility that this patient is a victim of physical abuse is premature without concrete evidence. Assessing for old injuries should be done first to gather information before taking further action.
A client with catatonic schizophrenia has been posturing, standing with his left arm upraised and his right foot off the floor. For the most part, he ignores attempts at nursing intervention but will occasionally walk, sit, or lie down for a few minutes. The client eats standing up if the nurse brings a tray to the room. The priority nursing order would be to:
- A. Insist that client sit or lie down for 30 minutes hourly
- B. Assess for lower extremity edema bid
- C. Provide high-calorie drinks hourly
- D. Take client to activities therapy once daily
Correct Answer: B
Rationale: The correct answer is B: Assess for lower extremity edema bid. It is important to assess for lower extremity edema in this client with catatonic schizophrenia as posturing in a standing position for prolonged periods can lead to decreased circulation and potential development of edema. This assessment is crucial to monitor the client's physical health and prevent complications such as deep vein thrombosis.
Choice A is incorrect as insisting the client sit or lie down for 30 minutes hourly may not address the underlying issue of potential lower extremity edema and could potentially worsen the client's condition by causing distress.
Choice C is incorrect as providing high-calorie drinks hourly does not address the immediate physical health concern of lower extremity edema and may not be appropriate without a comprehensive assessment of the client's nutritional needs.
Choice D is incorrect as taking the client to activities therapy once daily does not address the immediate need for assessing lower extremity edema and may not be suitable if the client's physical health
A Hispanic woman comes to the mental health center at the urging of her adult children. The patient has lost 5 pounds since her husband's death 6 months ago and says, "My husband comes to visit me in the night but I cannot understand what he says." How should the nurse analyze this situation? The patient is:
- A. Experiencing auditory and visual hallucinations.
- B. At high risk for imbalanced nutrition.
- C. Grieving the husband's death.
- D. Denying the husband's death.
Correct Answer: C
Rationale: The correct answer is C: Grieving the husband's death. The patient's statement about her deceased husband visiting her in the night and her weight loss following his death indicate a strong possibility of experiencing grief. This is a common manifestation of bereavement, where individuals may have difficulty accepting the reality of the loss and experience hallucinations or illusions involving the deceased. The patient's symptoms are more aligned with the normal process of grieving rather than psychosis. Choices A and B are incorrect because the patient's experiences are likely related to grief rather than auditory and visual hallucinations or imbalanced nutrition. Choice D is incorrect as the patient's statements suggest she is aware of her husband's death but is struggling to cope with it emotionally.
The persistent eating of nonfood items such as clay, laundry starch, insects, leaves, or pebbles that lasts for longer than 1 month is called:
- A. pica.
- B. bulimia.
- C. rumination.
- D. regurgitation.
Correct Answer: A
Rationale: Sure! The correct answer is A: pica. Pica is the persistent consumption of nonfood items lasting longer than 1 month. This condition is characterized by cravings for non-nutritive, nonfood substances. Bulimia (B) is a different eating disorder involving binge eating followed by purging behaviors. Rumination (C) is the repeated regurgitation and rechewing of food. Regurgitation (D) is the act of bringing swallowed food back to the mouth without nausea or retching.