While caring for an 88-year-old client suspected of having dementia, the nurse assesses the client for a common delusional thought. Which of the following would the nurse interpret as a common delusion?

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Question 1 of 9

While caring for an 88-year-old client suspected of having dementia, the nurse assesses the client for a common delusional thought. Which of the following would the nurse interpret as a common delusion?

Correct Answer: D

Rationale: The correct answer is D: My roommate keeps stealing my clothes. This delusion is common in dementia patients, involving paranoia and mistrust. It is plausible and related to daily life, making it more likely in dementia. Choices A, B, and C are grandiose and persecutory delusions, which are less common in dementia and more characteristic of other mental health conditions.

Question 2 of 9

The nurse is assessing a group of patients on an inpatient psychiatric unit. The patient's history for which of the following would the nurse identify as the strongest indicator of risk for violence?

Correct Answer: D

Rationale: The correct answer is D, violent behavior. This is the strongest indicator of risk for violence because past behavior is a significant predictor of future behavior. Patients with a history of violent behavior are more likely to exhibit violent tendencies in the future. Assessing for this history allows the nurse to implement appropriate interventions to prevent harm to self or others. Incorrect Choices: A: Panic disorder - Panic disorder is characterized by recurrent panic attacks and is not directly associated with an increased risk of violence. B: Problematic anxiety - While anxiety can contribute to agitation and irritability, it is not as strong of an indicator for violence compared to a history of violent behavior. C: Somatoform disorder - Somatoform disorder involves physical symptoms with no identifiable medical cause and is not typically associated with an increased risk of violence.

Question 3 of 9

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 4 of 9

A nurse working at the clinic is teaching a group of clients who are pregnant on the use of nonpharmacological pain management. Which of the following statements by the nurse is an appropriate description of the use of hypnosis during labor?

Correct Answer: B

Rationale: Rationale for correct answer (B): Hypnosis promotes increased control of pain perception by helping the individual focus on positive suggestions and imagery, reducing the perception of pain during contractions. By using hypnosis, the pregnant individual can learn to manage and cope with labor pain more effectively. Summary of incorrect choices: A: Biofeedback is a separate technique from hypnosis, focusing on monitoring and controlling physiological responses. C: Therapeutic touch is a different nonpharmacological pain management technique that involves the use of touch to promote relaxation, not specifically related to hypnosis. D: While hypnosis can provide guidance and suggestions, its primary focus is on enhancing control over pain perception rather than solely minimizing pain.

Question 5 of 9

What term refers to the pain that has a slower onset, is diffuse, radiates, and is marked by somatic pain from organs in any body activity?

Correct Answer: D

Rationale: Visceral pain refers to pain originating from internal organs. It has a slower onset, is diffuse, and often radiates. Somatic pain refers to pain originating from the skin, muscles, or bones, not internal organs. Acute pain is sudden and short-lived, not slow onset. Chronic pain is persistent and long-lasting, not necessarily marked by somatic pain from internal organs. Superficial pain is pain originating from the surface of the body, not internal organs. Therefore, the correct answer is D (visceral pain) as it aligns with the characteristics described in the question.

Question 6 of 9

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 7 of 9

A group of nursing students is reviewing information about the types of abuse. The students demonstrate understanding of the information when they identify stalking as a crime of which of the following?

Correct Answer: B

Rationale: The correct answer is B: Intimidation. Stalking is a crime that involves persistent and unwanted attention, behavior, or contact that instills fear or intimidation in the victim. Stalking is not necessarily always accompanied by physical violence (choice A), jealousy (choice C), or fear (choice D). Intimidation, on the other hand, accurately captures the coercive and fear-inducing nature of stalking behavior. Stalking behavior aims to control, scare, or manipulate the victim through persistent unwanted contact and surveillance.

Question 8 of 9

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 9 of 9

Which nursing intervention would establish trust with a client who is experiencing concrete thinking?

Correct Answer: A

Rationale: The correct answer is A because consistency in adhering to unit guidelines provides a structured environment that can help a client experiencing concrete thinking feel safe and secure. It establishes predictability, which is crucial for building trust. Calling the client by name (B) is a common courtesy but may not directly address the client's concrete thinking. Sharing what the client is feeling (C) may not be effective as the client may have difficulty understanding or processing emotions. Teaching the meaning of idioms (D) is irrelevant to establishing trust with a client experiencing concrete thinking.

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