Mental Health Exam Two
An older adult drove to a nearby store but was unable to remember how to get home or state an address. When police took the person home, the spouse reported frequent wandering into neighbors' homes. Alzheimer disease was subsequently diagnosed. Which stage of Alzheimer disease is evident?
2 (moderate)
A patient asks for information about Alcoholics Anonymous (AA). Which is the nurse's best response? a. "It is a self-help group with the goal of sobriety." b. "It is a form of group therapy led by a psychiatrist." c. "It is a group that learns about drinking from a group leader." d. "It is a network that advocates strong punishment for drunk drivers."
A. "It is a self-help group with the goal of sobriety." Reason: AA is a peer support group for recovering alcoholics. The goal is to maintain sobriety. Neither professional nor peer leaders are appointed.
A patient newly diagnosed with pancreatic cancer says, "My father also died of pancreatic cancer. I took care of him during his illness. I can't go through that." Select the highest priority nursing diagnosis.
Risk for suicide
A nurse working with a person whose spouse recently died uses cheer and humor to lift the person's spirits. At one point, the widowed person smiles briefly. What analysis of this scenario is correct?
The nurse needs help developing therapeutic communication.
An adult tells the nurse, "My partner abuses me most often when drinking. The drinking has increased lately, but I always get an apology afterward and a box of candy. I've considered leaving but haven't been able to bring myself to actually do it." Which phase in the cycle of violence prevents the patient from leaving? a. Tension building b. Acute battering c. Honeymoon d. Recovery
c. Honeymoon
A patient with anorexia nervosa virtually stopped eating 5 months ago and has lost 25% of body weight. A nurse asks, "Describe what you think about your present weight and how you look." Which response by the patient is most consistent with the diagnosis?
" I'm fat and ugly."
A nurse and patient construct a no-suicide contract. Select the preferable wording.
"For the next 24 hours, I will not in any way attempt to harm or kill myself."
A nurse counsels a patient with recent suicidal ideation. Which is the nurse's most therapeutic comment?
"Let's consider which problems are very important and which are less important."
A patient diagnosed with metastatic brain cancer says, "I'm dying, but I'm still living. I want to be in control as long as I can." Which reply shows the nurse was actively listening?
"Your mind and spirit are healthy, although your body is frail."
The treatment team plans care for a person diagnosed with schizophrenia and cannabis abuse. The person has recently used cannabis daily and is experiencing increased hallucinations and delusions. Which principle applies to care planning? a. Consider each disorder primary and provide simultaneous treatment. b. The person will benefit from treatment in a residential treatment facility. c. Withdraw the person from cannabis, and then treat the schizophrenia. d. Treat the schizophrenia first, and then establish the goals for the treatment of substance abuse.
A. Consider each disorder primary and provide simultaneous treatment Reason: Dual diagnosis (co-occurring disorders) clinical practice guidelines for both outpatient and inpatient settings suggest that the substance disorder and the psychiatric disorder should both be considered primary and receive simultaneous treatments. Residential treatment may or may not be effective.
A nurse with a history of narcotic abuse is found unconscious in the hospital locker room after overdosing. The nurse is transferred to an inpatient substance abuse unit for care. Which attitudes or behaviors by nursing staff may be enabling? a. Conveying understanding that pressures associated with nursing practice underlie substance abuse. b. Pointing out that work problems are the result, but not the cause, of substance abuse. c. Conveying empathy when the nurse discusses fears of disciplinary action by the state board of nursing. d. Providing health teaching about stress management.
A. Conveying understanding that pressures associated with nursing practice underlie substance abuse Reason: Enabling denies the seriousness of the patient's problem or supports the patient as he or she shifts responsibility from self to circumstances. The incorrect options are therapeutic and appropriate.
A patient diagnosed with bipolar disorder is dressed in a red leotard and bright scarves. The patient twirls and shadow boxes. The patient says gaily, "Do you like my scarves? Here; they are my gift to you." How should the nurse document the patient's mood? a. euphoric b. irritable c. suspicious d. confident
A. euphoric
A homeless patient diagnosed with severe and persistent mental illness became suspicious and delusional. The patient was given depot antipsychotic medication and housing was arranged at a local shelter. After 2 weeks, which statement by the patient indicates significant improvement? a. "I am feeling safe and comfortable here. Nobody bothers me." b. "They will not let me drink. They have many rules in the shelter." c. "Those guys are always watching me. I think someone stole my shoes." d. "That shot made my arm sore. I'm not going to take any more of them."
ANS: A Evaluation of a patient's progress is made based on patient satisfaction with the new health status and the health care team's estimation of improvement. For a formerly delusional patient to admit to feeling comfortable and free of being "bothered" by others denotes an improvement in the patient's condition. The other options suggest that the patient is in danger of relapse.
A patient experiencing acute mania dances around the unit, seldom sits, monopolizes conversations, interrupts, and intrudes. Which nursing intervention will best assist the patient with energy conservation? a. Monitor physiological functioning. b. Provide a subdued environment. c. Supervise personal hygiene. d. Observe for mood changes.
ANS: B All the options are reasonable interventions with a patient with acute mania, but providing a subdued environment directly relates to the outcome of energy conservation by decreasing stimulation and helping to balance activity and rest.
A man tells the nurse, "All my life, I have felt and acted like a woman while living in a man's body. For the past year, I have lived and dressed as a woman. I changed jobs to protect my new identity." Which request is the patient likely to make to the health care provider? a. "Can you refer me for psychological testing?" b. "Will you prescribe estrogen therapy? "c. "Will you alter my medical records?" d. "What should I tell my parents?"
ANS: B Before sexual reassignment surgery, the step that follows living as a member of the other sex is hormone therapy. The patient's decision to live as a woman makes this a natural request. Psychological testing occurs before sexual reassignment surgery, often after hormone therapy has begun. The patient has likely told his parents by this point.
A patient waves a newspaper and says, "I must have my credit card and use the computer right now. A store is having a big sale, and I need to order 10 dresses and four pairs of shoes." Select the nurse's appropriate intervention. The nurse: a. suggests the patient have a friend do the shopping and bring purchases to the unit. b. invites the patient to sit together and look at new fashion magazines. c. tells the patient computer use is not allowed until self-control improves. d. asks whether the patient has enough money to pay for the purchases.
ANS: B Situations such as this offer an opportunity to use the patient's distractibility to staff's advantage. Patients become frustrated when staff deny requests that the patient sees as entirely reasonable. Distracting the patient can avoid power struggles. Suggesting that a friend do the shopping would not satisfy the patient's need for immediacy and would ultimately result in the extravagant expenditure. Asking whether the patient has enough money would likely precipitate an angry response.
Which nursing diagnosis would most likely apply to both a patient diagnosed with major depression as well as one experiencing acute mania? a. Deficient diversional activity b. Disturbed sleep pattern c. Fluid volume excess d. Defensive coping
ANS: B Patients with mood disorders, both depression and mania, experience sleep pattern disturbances. Assessment data should be routinely gathered about this possible problem. Deficient diversional activity is more relevant for patients with depression. Defensive coping is more relevant for patients with mania. Fluid volume excess is less relevant for patients with mood disorders than is deficient fluid volume.
When making a distinction as to whether a patient is experiencing confusion related to depression or dementia, what information would be most important for the nurse to consider? a. The patient with dementia is persistently angry and hostile. b. Early morning agitation and hyperactivity occur in dementia. c. Confusion seems to worsen at night when dementia is present. d. A patient who is depressed is constantly preoccupied with somatic symptoms.
ANS: C Both dementia and depression in older adults may produce symptoms of confusion. Noting whether the confusion seems to increase at night, which occurs more often with dementia than with depression, will help distinguish whether depression or dementia is producing the confused behavior. The other options are not necessarily true.
While providing health teaching for a patient diagnosed with bulimia nervosa a nurse should emphasize information about: a. self-monitoring of daily food and fluid intake. b. establishing the desired daily weight gain. c. recognizing symptoms of hypokalemia. d. self-esteem maintenance.
ANS: C Hypokalemia results from potassium loss associated with vomiting. Physiologic integrity can be maintained if the patient can self-diagnose potassium deficiency and adjust the diet or seek medical assistance. Self-monitoring of daily food and fluid intake is not useful if the patient purges. Daily weight gain may not be desirable for a patient with bulimia nervosa. Self-esteem is an identifiable problem but is of lesser priority than the risk for hypokalemia.
Health maintenance and promotion efforts for patients diagnosed with severe and persistent mental illness should include education about the importance of regular: a. home safety inspections. b. monitoring of self-care abilities. c. screening for cancer, hypertension, and diabetes. d. determination of adequacy of a patient's support system.
ANS: C Individuals diagnosed with severe and persistent mental illness have an increased prevalence of medical disorders. Patients should be taught the importance of regular visits to a primary care physician for screening for these illnesses. Home safety inspections are more often suggested for patients with physical impairments. Caregivers and family members usually evaluate self-care abilities, rather than the patient. Assessment of a patient's support system is not usually considered part of health promotion and maintenance.
As a patient admitted to the eating disorders unit undresses a nurse observes that the patient's body is covered by fine downy hair. The patient weighs 70 pounds and is 5 feet 4 inches tall. Which condition should be documented? a. Amenorrhea b. Alopecia c. Lanugo d. Stupor
ANS: C The fine, downy hair noted by the nurse is called lanugo. It is frequently seen in patients with anorexia nervosa. None of the other conditions can be supported by the data the nurse has gathered.
A patient diagnosed with schizophrenia tells the community mental health nurse, "I threw away my pills because they interfere with God's voice." The nurse identifies the cause of the patient's ineffective management of the medication regimen as: a. inadequate discharge planning. b. poor therapeutic alliance with clinicians. c. impaired reasoning secondary to schizophrenia. d. dislike of the side effects of antipsychotic medications.
ANS: C The patient's ineffective management of the medication regimen is most closely related to impaired reasoning. The patient believes in being an exalted personage who hears God's voice, rather than an individual with a serious mental disorder who needs medication to control symptoms. Data do not suggest that any of the other factors often relate to medication nonadherence.
An adult says, "When I was a child, I took medication because I couldn't follow my teachers' directions. I stopped taking it when I was about 13. I still have trouble getting organized, which causes difficulty doing my job." Which disorder is most likely? a. Stress intolerance disorder b. Generalized anxiety disorder (GAD) c. Borderline personality disorder d. Adult attention deficit hyperactivity disorder (ADHD)
ANS: D Adult ADHD is usually diagnosed in early life and treated until adolescence. Treatment is often stopped because professionals think the disorder resolves itself because the hyperactive impulsive behaviors may diminish; the inattentive and disorganized behaviors tend to persist, however. Stress intolerance disorder is not found in the DSM-5. The scenario description is inconsistent with generalized anxiety disorder and borderline personality disorder.
A nurse conducting group therapy on the eating disorders unit schedules the sessions immediately after meals for the primary purpose of: a. maintaining patients' concentration and attention. b. shifting the patients' focus from food to psychotherapy. c. focusing on weight control mechanisms and food preparation. d. processing the heightened anxiety associated with eating.
ANS: D Eating produces high anxiety for patients with eating disorders. Anxiety levels must be lowered if the patient is to be successful in attaining therapeutic goals. Shifting the patients' focus from food to psychotherapy and focusing on weight control mechanisms and food preparation are not desirable. Maintaining patients' concentration and attention is important, but not the primary purpose of the schedule.
A 37-year-old is involuntarily committed to outpatient treatment after sexually molesting a 12-year-old child. The patient says, "That girl looked like she was 19 years old." Which defense mechanism is this patient using? a. Denial b. Identification c. Displacement d. Rationalization
ANS: D Rationalization is used to justify upsetting behaviors by creating reasons that would allow the individual to believe that the behaviors were warranted or appropriate. The patient is rationalizing molestation of a minor. Denial is used to avoid dealing with the problems and responsibilities related to one's behaviors. Identification is incorporating the image of an emulated person and then acting, thinking, and feeling like that person. Displacement is the discharge of pent-up feelings onto something or someone else in the environment that is less threatening than the original source of the feelings.
Which assessment finding for a patient diagnosed with an eating disorder meets criteria for hospitalization? a. Urine output 40 mL/hr b. Pulse rate 58 beats/min c. Serum potassium 3.4 mEq/L d. Systolic blood pressure 62 mm Hg
ANS: D Systolic blood pressure less than 70 mm Hg is an indicator for inpatient care. Many people without eating disorders have bradycardia (pulse less than 60 beats/min). Urine output should be more than 30 mL/hr. A potassium level of 3.4 mEq/L is within the normal range.
Shortly after a man's wife dies, the man approaches the nurse who cared for his wife during the final hours of life and says angrily, "If you had given her your undivided attention, she would still be alive." Which analysis applies?
Anger is a phenomenon experienced during grieving.
Over the past year, a woman has cooked gourmet meals for her family but eats only tiny servings. This person wears layered loose clothing. Her current weight is 95 pounds, a loss of 35 pounds. Which medical diagnosis is most likely? a.Binge eating b.Bulimia nervosa c.Anorexia nervosa d.Eating disorder not otherwise specified
Anorexia Nervosa
Which nursing intervention has the highest priority for a patient diagnosed with bulimia nervosa?
Assist the patient to identify triggers to binge eating
The spouse of a patient diagnosed with bipolar disorder asks what evidence supports the possibility of genetic transmission of bipolar disorders. Which response should the nurse provide? a. "A high proportion of patients with bipolar disorders are found among creative writers." b. "A higher rate of relatives with bipolar disorder is found among patients with bipolar disorder." c. "Patients with bipolar disorder have higher rates of relatives who respond in an exaggerated way to daily stress." d. "More individuals with bipolar disorder come from high socioeconomic and educational backgrounds.
B. "A higher rate of relatives with bipolar disorder is found among patients with bipolar disorder."
During the third week of treatment, the spouse of a patient in an alcoholism rehabilitation program says, "After discharge, I'm sure everything will be just fine." Which remark by the nurse will be most helpful to the spouse? a. "It is good that you're supportive of your spouse's sobriety and want to help maintain it." b. "Although sobriety solves some problems, new ones may emerge as one adjusts to living without alcohol." c. "It will be important for you to structure life to avoid as much stress as possible. You will need to provide social protection."
B. :Although sobriety solves some problems. new ones may emerge as one adjusts to living without alcohol."Reason: During recovery, patients identify and use alternative coping mechanisms to reduce their reliance on alcohol. Physical adaptations must occur. Emotional responses, formerly dulled by alcohol, are now fully experienced and may cause considerable anxiety. These changes inevitably have an effect on the spouse and children, who should be given anticipatory guidance and accurate information.
A patient with a history of daily alcohol abuse was hospitalized at 0200 today. When would the nurse expect withdrawal symptoms to peak?
B. Between 0200 tomorrow and hospital day 2 (24 to 48 hours after drinking stopped) Reason: Alcohol withdrawal usually begins 6 to 8 hours after cessation or significant reduction of alcohol intake. It peaks between 24 and 48 hours, then resolves or progresses to delirium
Which intervention is appropriate to use for patients diagnosed with either delirium or dementia? a. Speak in a loud, firm voice. b. Touch the patient before speaking. c. Reintroduce the health care worker at each contact. d. When the patient becomes aggressive, use physical restraint instead of medication.
C - reintroduce the health care worker at each contact
A patient diagnosed with bipolar disorder becomes hyperactive after discontinuing lithium. The patient threatens to hit another patient. Which comment by the nurse is appropriate? a. "Stop that! No one did anything to provoke an attack by you." b. "If you do that one more time, you will be secluded immediately." c. "Do not hit anyone. If you are unable to control yourself, we will help you." d. "You know we will not let you hit anyone. Why do you continue this behavior?"
C. "Do not hit anyone. If you are unable to control yourself, we will help you."
A patient was admitted 48 hours ago for injuries sustained while intoxicated. The patient is shaky, irritable, anxious, and diaphoretic. The pulse rate is 130 beats per minute. The patient shouts, "Snakes are crawling on my bed. I've got to get out of here." What is the most accurate assessment of the situation? The patient: a. is attempting to obtain attention by manipulating staff. b. may have sustained a head injury before admission. c. has symptoms of alcohol withdrawal delirium. d. is having a recurrence of an acute psychosis.
C. Has symptoms of alcohol withdrawal delirium Reason: Symptoms of agitation, elevated pulse, and perceptual distortions point to alcohol withdrawal delirium, a medical emergency. The findings are inconsistent with manipulative attempts, head injury, or functional psychosis.
A patient who was admitted for a heroin overdose received naloxone (Narcan), which improved the breathing pattern. Two hours later, the patient reports muscle aches, abdominal cramps, gooseflesh and says, "I feel terrible." Which analysis is correct? a. The patient is exhibiting a prodromal symptom of seizures. b. An idiosyncratic reaction to naloxone is occurring. c. Symptoms of opiate withdrawal are present. d. The patient is experiencing a relapse.
C. Symptoms of opiate withdrawal are present Reason: The symptoms given in the question are consistent with narcotic withdrawal and result from administration of naloxone. Early symptoms of narcotic withdrawal are flulike in nature. Seizures are more commonly observed in alcohol withdrawal syndrome.
The nursing care plan for a patient diagnosed with anorexia nervosa includes the interventions " monitor for complications of referring." Which body system should a nurse monitor closely for dysfunction?
Cardiovascular
What is the priority intervention for a patient diagnosed with delirium who has fluctuating levels of consciousness, disturbed orientation, and perceptual alterations?
Careful observation and supervision
A patient with a history of daily alcohol abuse says, "Drinking helps me cope with being a single parent." Which response by the nurse would help the individual conceptualize the drinking more objectively? a. "Sooner or later, alcohol will kill you. Then what will happen to your children?" b. "I hear a lot of defensiveness in your voice. Do you really believe this?" c. "If you were coping so well, why were you hospitalized again?" d. "Tell me what happened the last time you drank."
D. "Tell me what happened the last time you drank." Reason: The individual is rationalizing. The correct response will help the patient see alcohol as a cause of the problems, not the solution. This approach can also help the patient become receptive to the possibility of change. The incorrect responses directly confront and attack defenses against anxiety that the patient still needs. They reflect the nurse's frustration with the patient.
A woman in the last trimester of pregnancy drinks 8 to 12 ounces of alcohol daily. The nurse plans for the delivery of an infant who is: a. jaundiced. b. dependent on alcohol. c. healthy but underweight. d. microcephalic and cognitively impaired.
D. Microcephalic and cognitively impaired Reason: Fetal alcohol syndrome is the result of alcohol's inhibiting fetal development in the first trimester. The fetus of a woman who drinks that much alcohol will probably have this disorder. Alcohol use during pregnancy is not likely to produce the findings listed in the distractors.
Which treatment approach is most appropriate for a patient with antisocial tendencies who has been treated several times for substance addiction but has relapsed? a. One-week detoxification program b. Long-term outpatient therapy c. Twelve-step self-help program d. Residential program
D. Residential program Reason: Residential programs and therapeutic communities have goals of complete change in lifestyle, abstinence from drugs, elimination of criminal behaviors, development of employable skills, self-reliance, and honesty. Residential programs are more effective than outpatient programs for patients with antisocial tendencies.
Outpatient treatment is planned for a patient diagnosed with anorexia nervosa. Select the most important outcome related to nursing diagnosis: imbalanced nutrition, less than body requirements, within 1 week the patient will:
Gain 1-2 lbs
An adult has recently been absent from work for 3-day periods on several occasions. Each time, the individual returns wearing dark glasses. Facial and body bruises are apparent. What is the occupational health nurse's priority assessment?
How did this happen to you? (physical injuries)
A patient diagnosed with stage 1 Alzheimer disease tires easily and prefers to stay home rather than attend social activities. The spouse does the grocery shopping because the patient cannot remember what to buy. Which nursing diagnosis applies at this time?
Impaired memory
An older adult diagnosed with moderate-stage dementia forgets where the bathroom is and has episodes of incontinence. Which intervention should the nurse suggest to the patient's family?
Label the bathroom door
Which environmental adjustment should the nurse make for a patient experiencing delirium with perceptual alterations?
Provide a well-lit room without glare or shadows. Limit noise and stimulation.
A person intentionally overdosed on antidepressants. Which nursing diagnosis has the highest priority?
Risk for suicide
Disturbed body image is the nursing diagnosis for a patient diagnosed with an eating disorder. Which outcome indicator is most appropriate to monitor?
The patient expresses satisfaction with body appearance
A patient who was referred to the eating disorders clinic has lost 35 pounds in the past 3 months. to assess the patient oral intake a nurse should ask:
What do you eat in a typical day?
Which family scenario presents the greatest risk for family violence?
a. An unemployed husband with low self-esteem, a wife who loses her job, and a developmentally delayed 3-year-old child
An elderly patient must be physically restrained. Who is responsible for the patient's safety?
a. The nurse assigned to care for the patient
A community mental health nurse wants to establish a relationship with a very withdrawn patient diagnosed with schizophrenia. The patient lives at home with a supportive family. Select the nurse's best plan.
a. Visit daily for 4 days, then every other day for 1 week; stay with patient for 20 minutes, accept silence; state when the nurse will return.
A victim of physical abuse by a domestic partner is treated for a broken wrist. The patient has considered leaving but says, "You stay together, no matter what happens." Which outcome should be met before the patient leaves the emergency department? The patient will: a. name two community resources that can be contacted. b. limit contact with the abuser by obtaining a restraining order. c. demonstrate insight into the abusive relationship. d. facilitate counseling for the abuser.
a. name two community resources that can be contacted.
An adolescent comes to the crisis clinic and reports sexual abuse by an uncle. The adolescent told both parents about the uncle's behavior, but the parents did not believe the adolescent. What type of crisis exists?
b. Adventitious
A nurse visits the home of an 11-year-old child and finds the child caring for three younger siblings. Both parents are at work. The child says, "I want to go to school but we can't afford a babysitter. It doesn't matter though; I'm too dumb to learn." What preliminary assessment is evident? a. Insufficient data are present to make an assessment b. Child and siblings are experiencing neglect. c. Children are at high risk for sexual abuse. d. Children are experiencing physical abuse.
b. Child and siblings are experiencing neglect.
A patient diagnosed with schizophrenia says, "My co-workers are out to get me. I also saw two doctors plotting to kill me." How does this patient perceive the environment?
b. Dangerous
A clinic nurse interviews a patient who reports fatigue, back pain, headaches, and sleep disturbances. The patient seems tense, then becomes reluctant to provide more information, and is in a hurry to leave. How can the nurse best serve the patient? a. Explore the possibility of patient social isolation. b. Have the patient fill out an abuse assessment screen. c. Ask whether the patient has ever had psychiatric counseling. d. Ask the patient to disrobe; then assess for signs of physical abuse.
b. Have the patient fill out an abuse assessment screen.
A 79-year-old white male tells a nurse, "I have felt very sad lately. I do not have much to live for. My family and friends are all dead, and my own health is failing." The nurse should analyze this comment as:
b. evidence of risks for suicide. ANS: BThe patient describes loss of significant others, economic security, and health. He describes mood alteration and voices the thought that he has little to live for. Combined with his age, sex, and single status, each is a risk factor for suicide. Elderly white males have the highest risk for completed suicide.
The health care provider prescribes medication for a child diagnosed with attention deficit hyperactivity disorder (ADHD). The desired behavior for which the nurse should monitor is: a.increased expressiveness in communicating with others. b.improved ability for cooperative play with other children. c.ability to identify anxiety and implement self-control strategies. d.improved socialization skills with other children and authority figures.
b.improved ability for cooperative play with other children.
A newly admitted patient diagnosed with schizophrenia says, "The voices are bothering me. They yell and tell me I am bad. I have got to get away from them." Select the nurse's most helpful reply .a. "Do you hear the voices often?" b. "Do you have a plan for getting away from the voices?" c. "I'll stay with you. Focus on what we are talking about, not the voices. " d. "Forget the voices and ask some other patients to play cards with you."
c. "I'll stay with you. Focus on what we are talking about, not the voices. "
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?
c. Medications the patient has recently taken ANS: C Delirium in the elderly produces symptoms of confusion. Medication interactions or adverse reactions are often a cause. The distracters do not give information important for delirium.
an advanced directive gives valid direction to health care providers when a patient is?
c. is unable to make decisions for self because of illness. ANS: C Advance directives are invoked when patients are unable to make their own health care decisions. The correct response is the most global answer. A diagnosis of cancer or Parkinson's disease does not mean the patient is unable to make a decision. For a patient with amyotrophic lateral sclerosis, there are other ways to communicate beyond speaking.
An adolescent diagnosed with generalized anxiety disorder says, "My parents focus all their attention on my brother instead of me. He's perfect in their eyes." Which type of therapy might promote the greatest change in this adolescent's behavior? a.Bibliotherapy b.Play therapy c.Family therapy d.Behavior modification therapy
c.Family therapy
A 15-year-old adolescent has run away from home six times. After the adolescent was arrested for prostitution, the parents told the court, "We can't manage our teenager." The adolescent is physically abusive to the mother and defiant with the father. The adolescent's problem is most consistent with criteria for: a.attention deficit hyperactivity disorder (ADHD). b.childhood depression. c.conduct disorder (CD). d.autism spectrum disorder (ASD).
c.conduct disorder (CD).
Withdrawn patients diagnosed with schizophrenia: a. are usually violent toward caregivers. b. universally fear sexual involvement with therapists. c. exhibit a high degree of hostility as evidenced by rejecting behavior. d. avoid relationships because they become anxious with emotional closeness.
d. avoid relationships because they become anxious with emotional closeness.
A patient diagnosed with schizophrenia tells the nurse, "I eat skiller. Tend to end. Easter. It blows away. Get it?" Select the nurse's best response.
d."I am having difficulty understanding what you are saying." When a patient's speech is loosely associated, confused, and disorganized, pretending to understand is useless.
A nurse assesses a 3-year-old diagnosed with autism spectrum disorder. Which finding is most associated with the child's disorder? The child: a.has occasional toileting accidents. b.is unable to read children's books. c.cries when separated from a parent. d.continuously rocks in place for 30 minutes.
d.continuously rocks in place for 30 minutes.
The feeling experienced by a patient that should be assessed by the nurse as most predictive of elevated suicide risk is
hopelessness.
The spouse of a patient in hospice care angrily tells the nurse, "The care provided by the aide and other family members is inadequate, so I must do everything myself. Can't anyone do things right?" The palliative care nurse should:
provide teaching about anticipatory grieving.
Goals and outcomes for an older adult patient experiencing delirium caused by fever and dehydration will focus on:
returning to premorbid levels of function