The nurse wants to assess for disturbances in circadian rhythms in a patient admitted for depression. Which question best implements this assessment?
a. "Do you ever see or hear things that others do not?"
b. "Do you have problems with short-term memory?"
c. "What are your worst and best times of day?"
d. "How would you describe your thinking?"
ANS: C
Mood changes throughout the day are related to circadian rhythms. Questions about sleep pattern would also be relevant to circadian rhythms. The question about seeing or hearing things is relevant to the assessment for illusions and hallucinations. The question about thinking is relevant to the assessment of thought processes. The other question is relevant to assessment of memory.
You might also like to view...
A patient with catatonic schizophrenia exhibits little spontaneous movement and demonstrates waxy flexibility. Which nursing intervention should receive the highest priority?
a. Conducting passive range-of-motion exercises b. Exposing the patient to auditory and visual stimuli c. Interacting with the patient as if he is responding d. Including the patient in a variety of milieu activities
A nurse is presenting an educational event to a local community group. The nurse is speaking about colorectal cancer. What would the nurse identify as a risk factor associated with colorectal cancer?
A) Over 50 years of age B) History of bowel obstruction C) Family history of stomach cancer D) Low-fat, low-protein, low-fiber diet
The nurse is assessing the ears of a patient who is African American. Which assessment finding should the nurse identify as abnormal?
1. During the Rinne test, the patient hears the sound by air conduction for an equal amount of time as by bone conduction. 2. The patient is able to hear whispers from 18 inches away. 3. The patient's cerumen is dark gray. 4. The patient's tympanic membrane is pearly gray.
The mental health nurse knows that milieu therapy goals include:
A) Selection of the "best" treatment for the client. B) The client's right to choose treatment and be responsible. C) Group therapy that emphasizes medication abstinence. D) Formal relationships with the nurses and doctors.