NR-326 Mental Health Nursing - Set 5 - Part 3

Correct Answer: Marked inability to sustain attention

Delirium centers on disturbed attention and awareness, so the client cannot focus, sustain, or shift attention and loses track partway through an answer. The fluctuating evening agitation and visual images fit that acute inattentive picture. Option b is incorrect because slow erosion of function across years belongs to Alzheimer disease, whose insidious course unfolds long before any hospital admission. Delirium builds within hours to days and is measured against yesterday's baseline. Option c is incorrect because arousal is altered in delirium, ranging from drowsy to hypervigilant across the same shift. Preserved clarity of consciousness is the feature that marks dementia, where content of thought fails while wakefulness holds. Option d is incorrect because recent memory suffers badly during an episode, alongside disorientation to time and place. Expecting the client to recall the afternoon accurately would set up a false reassurance about the severity of this change.

Correct Answer: "Thank you for telling me. I am concerned for your safety."

Believing her and naming safety as the concern is the response that keeps the door open. It validates the disclosure without steering her decision, which is what allows the conversation to continue toward resources. Option a is incorrect because asking why she stays puts her on trial for someone else's behaviour. The question carries blame, and clients who hear it usually stop talking and answer nothing further. Option c is incorrect because directing her to leave takes the decision out of her hands at the moment she needs control most. Separation also raises the danger, so the timing must be hers. Option d is incorrect because calling a twisted arm a rough patch reframes assault as ordinary friction. Minimising language tells her the nurse did not grasp what she risked saying out loud.

Correct Answer: Obtain vital signs and a urinalysis

An abrupt change in a stable dementia client means delirium until proven otherwise. Vital signs and a urinalysis screen for the infection that most often triggers it, and treating that cause restores the previous baseline. Option a is incorrect because progression of dementia never explains a decline that appeared across two days. Telling relatives to expect this change closes the search for a treatable problem while the client keeps deteriorating. Option b is incorrect because closer watching keeps the resident safe yet identifies nothing. Supervision belongs alongside the workup, not instead of it, since the drowsiness and lost continence point toward a physical illness needing treatment. Option c is incorrect because retesting cognition measures a score rather than finding the illness driving it. Any screening result gathered during an acute confusional episode reflects the delirium and cannot be interpreted as dementia severity.

Correct Answer: A situational crisis from an external event

Job loss is an unanticipated external event that upends a life without warning, which is the definition of a situational crisis. His collapsed sleep, appetite, and contact with others show coping has failed. Option a is incorrect because developmental crises attach to normative passages such as adolescence, marriage, parenthood, or retirement that arrive on a predictable timetable. Being laid off arrived without notice and belongs to no life stage. Option c is incorrect because adventitious events strike whole communities at once, as a tornado, a mass casualty shooting, or an epidemic does. One man losing one job affects a household, not a population. Option d is incorrect because that label requires a pre-existing illness such as severe depression to be driving the breakdown. Nothing in this history names a psychiatric diagnosis; an ordinary man met an extraordinary week.

Correct Answer: Ask the child alone to describe what happened

Open questions asked away from the caregiver let the child give an account in her own words. Leading questions contaminate what she says, and repeated interviews add nothing while forcing her to relive it. Option a is incorrect because naming a suspect inside the question tells the child what answer is wanted. A yes obtained that way is unusable later and may simply reflect her wish to please. Option b is incorrect because a child will not contradict an adult who is sitting beside her. Whoever brought her in may be the person she fears, so the interview happens without him. Option d is incorrect because secrecy is something the nurse can never promise. Reports must be made and the account will be shared with investigators, so a broken promise would cost the child's trust.

Correct Answer: Fingertips turning white and cold in cool weather

Colour change, numbness or coolness in the digits suggests peripheral vasculopathy, a recognised stimulant effect that must be reported. The other findings are expected or reassuring and are handled through timing and monitoring. Option b is incorrect because rebound irritability as blood levels fall is a common and anticipated pattern. It is managed by adjusting timing or formulation at a routine visit, not by an urgent call. Option c is incorrect because steady growth along an established percentile is the reassuring result. Plotting height and weight at every visit exists precisely to catch the child whose curve flattens, and this one has not. Option d is incorrect because insomnia is a well known stimulant effect with a straightforward fix. Moving the final dose to mid afternoon usually resolves it, so this warrants teaching rather than an urgent report.

Correct Answer: Name what she can see, hear and touch now

Sensory grounding pulls attention back to the present through sight, sound and touch. The nurse speaks calmly, uses the client's name and asks permission before any physical contact is offered. Option a is incorrect because digging for the trigger during an episode deepens the dissociation instead of ending it. Connections between triggers and symptoms are drawn later, when the client is grounded and calm. Option b is incorrect because unannounced restraint of the hands can replay the trauma that built the dissociation in the first place. Permission is asked before touching a client who dissociates. Option c is incorrect because isolation removes the calm external voice that helps the client reorient. A dissociating person is also a fall and wandering risk, so leaving her unobserved adds danger.

Correct Answer: A private room with dimmed lights and fewer alarms

Sensory overload drives most behavioural crises for autistic children in hospital. A low stimulus space with dim lighting, limited alarms and permission to use noise cancelling headphones prevents escalation before it starts. Option a is incorrect because a roommate adds conversation, visitors and unpredictable noise to an already overloaded system. Peer modelling is not how social communication difficulty in autism is addressed during an acute admission. Option c is incorrect because the area outside the nurses station is the loudest and busiest on any unit. Ringing phones, overhead pages and constant traffic would worsen exactly the sensitivities described here. Option d is incorrect because bold decoration and background music pile more input onto a child who is already overwhelmed. What soothes a neurotypical child can be genuinely painful for this one.

Correct Answer: Arrange adult day programming and respite care

These findings describe caregiver role strain, a clinical problem rather than a character flaw. Respite through day programming or in home help restores sleep and social contact, which prevents the crisis that forces an unplanned placement. Option a is incorrect because urging more patience treats exhaustion as a personal failing and adds guilt to an already depleted caregiver. Effort cannot substitute for rest, and nothing about the daily workload changes. Option b is incorrect because moving to a facility skips every less restrictive support and may not match what the family wants. Placement is planned deliberately over time, not proposed at the first sign of strain. Option d is incorrect because concealing feelings drives the problem underground and blocks honest reporting at the next visit. The daughter needs practical relief and permission to speak openly, not coaching in how to look composed.

Correct Answer: His grief is following an uncomplicated course

Grief arrives in waves and lifts between them, which is what laughing with the grandchildren shows. He is still eating, accepting company, and able to be comforted, so nothing here points to disorder. Option b is incorrect because that diagnosis needs a death at least twelve months earlier in an adult, plus daily yearning and a cluster of symptoms exceeding cultural norms. Three months is far too soon. Option c is incorrect because depression settles in and stays, draining pleasure from everything and attacking the person's worth. This man's sadness is tied to his wife, and his self esteem is intact. Option d is incorrect because delayed mourning means the reaction has been postponed or suppressed. He is crying openly and talking about her, so the work of grief is visibly under way.