Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a young adult client who has acute schizophrenic disorder and tells the nurse, "Yesterday noon the sun moon went over the rover to see the lawnmower.”. Which of the following manifestations is the client exhibiting?
A. Delusional disorder.
Delusional disorder is characterized by the presence of one or more delusions for a month or longer, which could be plausible but are not real. This is not the case here.
B. Anhedonia.
Anhedonia refers to the inability to experience pleasure, a common symptom in many mental disorders, including depression. It does not apply to this situation.
C. Associative looseness.
Associative looseness, or loose associations, is a thought disorder characterized by speech in which ideas shift from one subject to another that is unrelated or minimally related. The client’s statement is an example of this.
D. Hallucination.
Hallucinations are sensory experiences that occur in the absence of actual stimulation. The client’s statement is not a hallucination, but a disorganized thought process.
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Full Explanation
Choice A rationale:
Delusional disorder is characterized by the presence of one or more delusions for a month or longer, which could be plausible but are not real. This is not the case here.
Choice B rationale:
Anhedonia refers to the inability to experience pleasure, a common symptom in many mental disorders, including depression. It does not apply to this situation.
Choice C rationale:
Associative looseness, or loose associations, is a thought disorder characterized by speech in which ideas shift from one subject to another that is unrelated or minimally related. The client’s statement is an example of this.
Choice D rationale:
Hallucinations are sensory experiences that occur in the absence of actual stimulation. The client’s statement is not a hallucination, but a disorganized thought process.
Similar Questions
A nurse is assessing a client who has schizophrenia which has been treated with fluphenazine for several years.
Which of the following findings should the nurse document as manifestations of tardive dyskinesia (TD)?.
A. Twisting tongue movements.
Twisting tongue movements are a common symptom of tardive dyskinesia (TD), a side effect of long-term use of antipsychotic medications like fluphenazine.
B. Shuffling gait.
Shuffling gait is more commonly associated with Parkinson’s disease and certain antipsychotic medications can cause Parkinson-like symptoms, but it is not a characteristic of TD2.
C. Sudden onset of high fever.
Sudden onset of high fever is not associated with TD. It could be a sign of a serious condition like neuroleptic malignant syndrome, which requires immediate medical attention.
D. Constant tapping of feet when sitting.
Constant tapping of feet when sitting could be a sign of restlessness or akathisia, another potential side effect of antipsychotic medications, but it is not a specific sign of TD2.
Full Explanation
Choice A rationale:
Twisting tongue movements are a common symptom of tardive dyskinesia (TD), a side effect of long-term use of antipsychotic medications like fluphenazine.
Choice B rationale:
Shuffling gait is more commonly associated with Parkinson’s disease and certain antipsychotic medications can cause Parkinson-like symptoms, but it is not a characteristic of TD2.
Choice C rationale:
Sudden onset of high fever is not associated with TD. It could be a sign of a serious condition like neuroleptic malignant syndrome, which requires immediate medical attention.
Choice D rationale:
Constant tapping of feet when sitting could be a sign of restlessness or akathisia, another potential side effect of antipsychotic medications, but it is not a specific sign of TD2.
A nurse is caring for a client who has borderline personality disorder (BPD).
Check the 6 assessment findings that require immediate follow-up:.
A. Financial situation.
Financial instability is a suicide risk factor in clients with BPD, especially when combined with impulsivity, substance use, and recent bereavement. It requires urgent psychosocial and safety evaluation.
B. Increased use of mood-altering substances.
Increased use of mood-altering substances is a serious concern. The client has been drinking heavily and asking for their “nerve” pill, which could indicate substance misuse.
C. Sexual behaviors.
The client’s sexual behaviors, specifically having multiple partners and not using condoms, pose a risk for sexually transmitted infections.
D. Hepatitis Viral Study (HAA) results.
The positive Hepatitis Viral Study (HAA) indicates the presence of a viral hepatitis infection, which requires immediate medical attention.
E. BUN level.
The BUN level is within the normal range (10 to 20 mg/dL), so it does not require immediate follow-up.
F. Hgb level.
The Hgb level is within the normal range (12 to 18 g/dL), so it does not require immediate follow-up.
G. Sodium level.
The sodium level is below the normal range (136 to 145 mEq/L), indicating hyponatremia, which requires immediate medical attention.
H. Being admitted frequently
Frequent admissions suggest chronic instability but are not acutely life-threatening. It warrants care plan review but not immediate emergency follow-up.
I. Recent loss of a parent
The recent loss of a parent is a significant life event that could exacerbate the client’s mental health issues and substance misuse, requiring immediate follow-up.
A nurse is caring for a client in an outpatient clinic.
The nurse should identify which of the following findings as manifestations of somatic symptom disorder? (Select all that apply.).
A. Anxiety.
Anxiety is a common symptom of somatic symptom disorder, as patients often experience significant distress about their physical symptoms.
B. Gastrointestinal distress.
Gastrointestinal distress, such as stomach pain and diarrhea, can be manifestations of somatic symptom disorder. These symptoms can cause significant distress and disrupt daily life.
C. Pain.
Pain, especially when it is not linked to a clear physical cause, can be a symptom of somatic symptom disorder. The distress caused by the pain is often out of proportion to its severity.
D. Bipolar disorder.
Bipolar disorder is a separate mental health condition and is not a symptom of somatic symptom disorder.
E. Fixation on health.
Fixation on health, particularly an excessive preoccupation with physical symptoms, is a key feature of somatic symptom disorder.
F. Depression.
Depression can often co-occur with somatic symptom disorder, as the distress and disruption caused by the physical symptoms can lead to feelings of sadness and hopelessness.
G. Localized amnesia.
Localized amnesia is not a symptom of somatic symptom disorder. It is more commonly associated with other mental health conditions, such as dissociative disorders.
Full Explanation
Choice A rationale:
Anxiety is a common symptom of somatic symptom disorder, as patients often experience significant distress about their physical symptoms.
Choice B rationale:
Gastrointestinal distress, such as stomach pain and diarrhea, can be manifestations of somatic symptom disorder. These symptoms can cause significant distress and disrupt daily life.
Choice C rationale:
Pain, especially when it is not linked to a clear physical cause, can be a symptom of somatic symptom disorder. The distress caused by the pain is often out of proportion to its severity.
Choice D rationale:
Bipolar disorder is a separate mental health condition and is not a symptom of somatic symptom disorder.
Choice E rationale:
Fixation on health, particularly an excessive preoccupation with physical symptoms, is a key feature of somatic symptom disorder.
Choice F rationale:
Depression can often co-occur with somatic symptom disorder, as the distress and disruption caused by the physical symptoms can lead to feelings of sadness and hopelessness.
Choice G rationale:
Localized amnesia is not a symptom of somatic symptom disorder. It is more commonly associated with other mental health conditions, such as dissociative disorders.