Marco, age 83, has dementia and difficulty feeding himself despite the fact that there is nothing wrong with his motor functions. Which term should the nurse use to document this finding?

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Question 1 of 5

Marco, age 83, has dementia and difficulty feeding himself despite the fact that there is nothing wrong with his motor functions. Which term should the nurse use to document this finding?

Correct Answer: B

Rationale: The correct answer is B: Apraxia. Apraxia is the inability to perform purposeful movements despite the absence of motor or sensory impairment. In this case, Marco is experiencing difficulty feeding himself despite intact motor functions, indicating apraxia. A: Aphasia is the loss of ability to understand or express speech, which is not the case here. C: Agnosia is the inability to recognize objects or people, which is not relevant to Marco's situation. D: Disinhibition anergia is not a recognized term in the context of this question.

Question 2 of 5

What is the scope of psychiatric-mental health nursing practice?

Correct Answer: A

Rationale: The correct answer is A because psychiatric-mental health nursing practice involves assessing clients, providing education, administering medications, and screening for suicide risk. Assessment helps in understanding the client's mental health status. Education empowers clients to manage their condition. Medication administration ensures proper treatment. Suicide risk screening is crucial for client safety. Choices B, C, and D are incorrect as they include tasks outside the scope of psychiatric-mental health nursing such as medical diagnosis, giving orders, assisting with ADLs, and giving advice.

Question 3 of 5

A nurse is performing an admission assessment. The patient complains that it has been taking larger and larger amounts of medication to get the desired effect. Based on this information, the nurse interprets this as suggesting which of the following?

Correct Answer: B

Rationale: The correct answer is B: Tolerance. Tolerance refers to the body's reduced response to a drug over time, necessitating higher doses to achieve the same effect. In this scenario, the patient needing larger amounts of medication to achieve the desired effect indicates tolerance development. Desensitization (A) refers to reduced response due to receptor downregulation. Therapeutic index (C) is the ratio of a drug's effective dose to its toxic dose. Toxicity (D) is the harmful effects of a drug at excessive doses.

Question 4 of 5

A client with obsessive-compulsive disorder has been taking fluoxetine for 1 month. The client tells the nurse, These pills are making me sick. I think I'm getting a brain tumor because of the headaches. Which response by the nurse would be most appropriate?

Correct Answer: D

Rationale: Rationale: 1. Correct Answer (D): This response educates the client about a potential side effect of the medication, linking headaches to fluoxetine. It addresses the client's concern directly and provides accurate information. 2. Incorrect Answer (A): Focusing on rituals doesn't address the client's specific complaint of headaches and brain tumor fears. 3. Incorrect Answer (B): Asking about hand washing is unrelated to the client's symptoms of headaches and brain tumor fears. 4. Incorrect Answer (C): Inquiring about relaxation exercises doesn't address the client's concern about medication side effects causing headaches.

Question 5 of 5

A nurse is evaluating the outcomes for a client diagnosed with complex somatic symptom disorder. Which of the following would the nurse most likely identify as interfering with achievement?

Correct Answer: B

Rationale: The nurse would identify option B as interfering with achievement because addressing overall issues can be overwhelming and vague, making it difficult to measure progress effectively. Stating outcomes in realistic terms (A) is important for setting achievable goals. Indicating small successes (C) allows for incremental progress tracking. Identifying outcomes for specific behaviors (D) helps in defining clear targets for intervention. In summary, option B lacks specificity and may hinder the client's progress by not providing clear direction for goal attainment.

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