A 25 year old male is admitted to a mental health facility because of inappropriate behavior. The client has been hearing voices, responding to imaginary companions and withdrawing to his room for several days at a time. Nurse Monette understands that the withdrawal is a defense against the client’s fear of:
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Solution
Rejection
Option D: An aloof, detached, withdrawn posture is a means of protecting the self by withdrawing and maintaining a safe, emotional distance.
A nursing diagnosis for a male client with a diagnosed multiple personality disorder is chronic low self-esteem probably related to childhood abuse. The most appropriate short-term client outcome would be:
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Solution
Recognizing each existing personality
Option B: The client must recognize the existence of the sub-personalities so that interpretation can occur.
One morning a female client on the inpatient psychiatric service complains to nurse Hazel that she has been waiting for over an hour for someone to accompany her to activities. Nurse Hazel replies to the client “We’re doing the best we can. There are a lot of other people in the unit who needs attention too.” This statement shows that the nurse’s use of:
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Solution
Defensive behavior
Option A: The nurse’s response is not therapeutic because it does not recognize the client’s needs but tries to make the client feel guilty for being demanding.
Grace is exhibiting withdrawn patterns of behavior. Nurse Johnny is aware that this type of behavior eventually produces a feeling of:
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Solution
Loneliness
Option B: The withdrawn pattern of behavior presents the individual from reaching out to others for sharing the isolation produces feeling of loneliness.
When developing an initial nursing care plan for a male client with a Bipolar I disorder (manic episode) nurse Ron should plan to?
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Solution
Provide foods, fluids and rest
Option C: The client in a manic episode of the illness often neglects basic needs, these needs are a priority to ensure adequate nutrition, fluid, and rest.
The primary nursing diagnosis for a female client with a medical diagnosis of major depression would be:
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Solution
Impaired verbal communication related to depression
Option D: Depressed clients demonstrate decreased communication because of lack of psychic or physical energy.
Jerome who has an eating disorder often exhibits similar symptoms. Nurse Lhey would expect an adolescent client with anorexia to exhibit:
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Solution
Affective instability
Option A: Individuals with anorexia often display irritability, hospitality, and a depressed mood.
What is the priority care for a client with a dementia resulting from AIDS?
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Solution
Providing basic intellectual stimulation
Option C: This action maintains for as long as possible, the client’s intellectual functions by providing an opportunity to use them.
When taking a health history from a female client who has a moderate level of cognitive impairment due to dementia, the nurse would expect to note the presence of:
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Solution
Accentuated premorbid traits
Option A: A moderate level of cognitive impairment due to dementia is characterized by increasing dependence on environment & social structure and by increasing psychologic rigidity with accentuated previous traits & behaviors.
Joy’s stream of consciousness is occupied exclusively with thoughts of her father’s death. Nurse Ronald should plan to help Joy through this stage of grieving, which is known as:
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Solution
Resolving the loss
Option C: Resolving a loss is a slow, painful, continuous process until a mental image of the dead person, almost devoid of negative or undesirable features emerges.