Question: The family members of a patient newly diagnosed with schizophrenia state that they do not understand what has caused the illness. The nurse’s response should be based on which models? (Select all that apply.)
Answer Choices: a. Neurobiological b. Environmental c. Family theory d. Genetic e. Stress
Answer: a. Neurobiological d. Genetic
Question: A nurse at the mental health clinic plans a series of psychoeducational groups for persons diagnosed with schizophrenia. Which two topics would take priority? (Select all that apply.)
Answer Choices: a. How to complete an application for employment? b. The importance of correctly taking your medication. c. How to dress when attending community events? d. How to give and receive compliments? e. Ways to quit smoking.
Answer: b. The importance of correctly taking your medication. e. Ways to quit smoking.
Question: A patient diagnosed with schizophrenia is hospitalized after arguing with coworkers and threatening to harm them. The patient is aloof and suspicious and says, “Two staff members I saw talking were plotting to assault me.” Based on data gathered at this point, which nursing diagnoses relate? (Select all that apply.)
Answer Choices: a. Risk for other-directed violence b. Disturbed thought processes c. Risk for loneliness d. Spiritual distress e. Social isolation
Answer: a. Risk for other-directed violence b. Disturbed thought processes
Question: An older adult takes digoxin and hydrochlorothiazide daily, as well as lorazepam as needed for anxiety. Over 2 days, this adult developed confusion, slurred speech, an unsteady gait, and fluctuating levels of orientation. These findings are most characteristic of which adverse reaction to the medication therapy?
Answer Choices: a. Delirium b. Dementia c. Amnestic syndrome d. Alzheimer’s disease
Answer: a. Delirium
Question: A patient experiencing fluctuating levels of awareness, confusion, and disturbed orientation shouts, “Bugs are crawling on my legs! Get them off!” Which problem is the patient experiencing?
Answer Choices: a. Aphasia b. Dystonia c. Tactile hallucinations d. Mnemonic disturbance
Answer: c. Tactile hallucinations
Question: A patient experiencing fluctuating levels of consciousness, disturbed orientation, and perceptual alteration begs, “Someone get these bugs off me.” What is the nurse’s best response?
Answer Choices: a. “There are no bugs on your legs. Your imagination is playing tricks on you.” b. “Try to relax. The crawling sensation will go away sooner if you can relax.” c. “Don’t worry. I will have someone stay here and brush off the bugs for you.” d. “I don’t see any bugs, but I know you are frightened so I will stay with you.”
Answer: d. “I don’t see any bugs, but I know you are frightened so I will stay with you.”
Question: What is the priority nursing diagnosis for a patient experiencing fluctuating levels of consciousness, disturbed orientation, and visual and tactile hallucinations?
Answer Choices: a. Bathing/hygiene self-care deficit related to altered cerebral function as evidenced by confusion and inability to perform personal hygiene tasks b. Risk for injury related to altered cerebral function, misperception of the environment, and unsteady gait c. Disturbed thought processes related to medication intoxication as evidenced by confusion, disorientation, and hallucinations d. Fear related to sensory perceptual alterations as evidenced by hiding from imagined ferocious dogs
Answer: b. Risk for injury related to altered cerebral function, misperception of the environment, and unsteady gait
Question: What is the priority nursing intervention for a patient diagnosed with delirium who has fluctuating levels of consciousness, disturbed orientation, and perceptual alterations?
Answer Choices: a. Avoidance of physical contact b. High level of sensory stimulation c. Careful observation and supervision d. Application of wrist and ankle restraints
Answer: c. Careful observation and supervision
Question: Which environmental adjustment should the nurse make for a patient experiencing delirium with perceptual alterations?
Answer Choices: a. Keep the patient by the nurse’s desk while the patient is awake. Provide rest periods in a room with a television on. b. Light the room brightly, day and night. Awaken the patient hourly to assess mental status. c. Maintain soft lighting day and night. Keep a radio on low volume continuously. d. Provide a well-lit room without glare or shadows. Limit noise and stimulation.
Answer: d. Provide a well-lit room without glare or shadows. Limit noise and stimulation.
Question: Which description of patient behavior best applies to a hallucination?
Answer Choices: a. Looking at shadows on a wall and says, “I see scary faces” b. Stating, “I feel bugs crawling on my legs and biting me” c. Becoming anxious when the nurse leaves his or her bedside d. Trying to hit the nurse when vital signs are taken
Answer: b. Stating, “I feel bugs crawling on my legs and biting me”
Question: Consider these health problems: Lewy body disease, Pick disease, and Parkinson’s disease. Which term unifies these problems?
Answer Choices: a. Intoxication b. Dementia c. Delirium d. Amnesia
Answer: b. Dementia
Question: When used for treatment of patients diagnosed with Alzheimer’s disease, which medication would be expected to antagonize N-methyl-D-aspartate (NMDA) channels rather than cholinesterase?
Answer Choices: a. Donepezil b. Rivastigmine c. Memantine d. Galantamine
Answer: c. Memantine
Question: An older adult was stopped by police for driving through a red light. When asked for a driver’s license, the adult hands the police officer a pair of sunglasses. What sign of dementia is evident?
Answer Choices: a. Aphasia b. Apraxia c. Agnosia d. Memory impairment
Answer: c. Agnosia
Question: 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. Which stage of Alzheimer’s disease is evident?
Answer Choices: a. 1 (mild) b. 2 (moderate) c. 3 (moderate to severe) d. 4 (late)
Answer: b. 2 (moderate)
Question: Which condition is characterized with apolipoprotein E (apoE) malfunction, neuritic plaques, neurofibrillary tangles, granulovascular degeneration, and brain atrophy?
Answer Choices: a. Alzheimer’s disease b. Wernicke encephalopathy c. Central anticholinergic syndrome d. Acquired immunodeficiency syndrome (AIDS)-related dementia
Answer: a. Alzheimer’s disease
Question: A patient diagnosed with stage 1 mild Alzheimer’s 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?
Answer Choices: a. Complicated grieving b. Impaired memory c. Self-care deficit d. Caregiver role strain
Answer: b. Impaired memory
Question: A patient has progressive memory deficit associated with dementia. Which nursing intervention would best help the individual function in the environment?
Answer Choices: a. Assist the patient to perform simple tasks by giving step-by-step directions. b. Provide the patient with current newspapers and magazines to read. c. Explain the intellectual functions of daily living for the patient. d. Discuss intellectual functions and new topics with the patient.
Answer: a. Assist the patient to perform simple tasks by giving step-by-step directions.