ATI LPN
Test Bank for Essentials of Psychiatric Mental Health Nursing: A Communication Approach to Evidence-Based Care, 4e 4th Edition
Chapter 18 Questions
Question 1 of 5
What is the priority nursing diagnosis for a patient experiencing fluctuating levels of consciousness, disturbed orientation, and visual and tactile hallucinations?
Correct Answer: B
Rationale: The physical safety of the patient is the highest priority among the diagnoses given. Many opportunities for injury exist when a patient misperceives the environment as distorted, threatening, or harmful; when the patient exercises poor judgment; and when the patient's sensorium is clouded. The other diagnoses may be concerns but are lower priorities.
Question 2 of 5
A hospitalized patient experiencing delirium misinterprets reality and a patient diagnosed with dementia wanders about the home. Which outcome is the priority in both scenarios?
Correct Answer: A
Rationale: Risk for injury is the nurse's priority concern in both scenarios. Safety maintenance is the desired outcome. The other outcomes may not be realistic.
Question 3 of 5
Two patients in a residential care facility are diagnosed with dementia. One shouts to the other, 'Move along, you're blocking the road.' The other patient turns, shakes a fist, and shouts, 'I know what you're up to; you're trying to steal my car.' What is the nurse's best action?
Correct Answer: C
Rationale: Separating and distracting prevents escalation from verbal to physical acting out. Neither patient loses self-esteem during this intervention. Medication is probably not necessary.
Stepping between two angry, threatening patients is an unsafe action, and trying to reinforce reality during an angry outburst will probably not be successful when the patients are cognitively impaired.
Question 4 of 5
What is the priority nursing need for a patient diagnosed with late-stage dementia?
Correct Answer: C
Rationale: In late-stage dementia, the patient has often forgotten how to eat, chew, and swallow. Nutrition and hydration needs must be met if the patient is to live. The patient is incapable of self-care, ambulation, or verbal communication.
Question 5 of 5
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?
Correct Answer: C
Rationale: The patient feels bugs crawling on both legs, although no sensory stimulus is actually present. This description coincides with the definition of a hallucination, a false sensory perception. Tactile hallucinations may be part of the symptom constellation of delirium. Aphasia refers to a speech disorder. Dystonia refers to excessive muscle tonus. Mnemonic disturbance is associated with dementia rather than delirium.