A patient with fluctuating levels of awareness, confusion, and disturbed orientation shouts, 'Bugs are crawling on my legs.' Which problem is the patient experiencing?

Correct Answer: C

Rationale: The correct answer is C: Tactile hallucinations. The patient's complaint of bugs crawling on their legs indicates a sensory perception disturbance, which is characteristic of tactile hallucinations. This symptom is commonly associated with conditions like schizophrenia or substance use. Aphasia (A) is a language disorder, not related to sensory perceptions. Dystonia (B) is a movement disorder, not associated with hallucinations. Mnemonic disturbance (D) refers to memory issues, not sensory hallucinations. In this case, the patient's symptom points to a sensory perception distortion, making tactile hallucinations the most appropriate choice.

Correct Answer: C

Rationale: Rationale: Choice C (Paranoid delusions of being followed by alien monsters) predicts the highest risk for directing violent behavior as paranoid delusions can lead to extreme fear and aggression towards perceived threats. Delusions of being followed by alien monsters can trigger a sense of imminent danger, leading to potentially violent actions. In contrast, choices A, B, and D are less likely to directly result in violent behavior towards others. Major depressive disorder with delusions of worthlessness (A) may lead to self-harm but not necessarily violence towards others. Obsessive-compulsive disorder (B) is characterized by repetitive behaviors and thoughts, not typically violent tendencies. Completed alcohol withdrawal and beginning a rehabilitation program (D) indicate a positive step towards recovery, reducing the risk of violent behavior.

Correct Answer: A

Rationale: The correct answer is A: make sure there is adequate physical space between the nurse and patient. This is the best course of action to ensure the safety of both the nurse and the patient. By maintaining physical distance, the nurse can prevent any potential harm or escalation of the situation. It allows the patient to have personal space and reduces the risk of physical confrontation. Moving closer (B) or maintaining an arm's length distance (C) may provoke the patient further. Initiating a conversation about appropriate behavior (D) can be ineffective or even escalate the situation without first ensuring physical safety.

Correct Answer: D

Rationale: The correct answer is D because it acknowledges the widow's emotions, validates her feelings, and expresses empathy. It shows understanding and support without making assumptions or judgments about her condition. A: This response jumps to conclusions about hallucinations, which may not be relevant to the widow's situation. B: This response invalidates the widow's grief and may increase her feelings of guilt or shame. C: This response stigmatizes the widow's mental illness and suggests a drastic intervention without assessing her current needs.

Correct Answer: B

Rationale: The correct answer is B because it reflects a healthy progression through the grieving process. Remembering both the positive and negative aspects of the relationship indicates acceptance and a realistic view. Choice A suggests a lack of progress as the widow has not moved on from keeping belongings untouched. Choice C indicates unresolved grief with continued attachment. Choice D signals emotional suppression and denial of grief, which is not indicative of successful mourning. In summary, choice B demonstrates a balanced and adaptive response to grief, while the other options reflect various stages of unresolved or maladaptive grieving.