A catatonic client admitted in a stuporous condition begins to demonstrate increased motor activity
He sometimes walks slowly around the unit without interacting.
One day the nurse observes him
standing immobile, facing the wall with one arm bent behind his back and the other extended in a
Nazi-like salute. He remains immobile in that position for 15 minutes, moving only when the nurse
gently lowers his arm. This phenomenon is termed
a. echolalia.
b. waxy flexibility.
c. depersonalization.
d. thought withdrawal.
B
Waxy flexibility is the ability to hold distorted postures for extended periods of time, as though the
client were molded in wax. Option A: Echolalia is a speech pattern. Option C: Depersonalization
refers to a feeling state. Option D: Thought withdrawal refers to an alteration in thinking.
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A nurse is caring for a patient who has been admitted to the hospital with diverticulitis. Which of the following would be appropriate nursing diagnoses for this patient? Select all that apply
A) Acute Pain Related to Increased Peristalsis and GI Inflammation B) Activity Intolerance Related to Generalized Weakness C) Bowel Incontinence Related to Increased Intestinal Peristalsis D) Deficient Fluid Volume Related to Anorexia, Nausea, and Diarrhea E) Impaired Urinary Elimination Related to GI Pressure on the Bladder
The nurse suspects child abuse in which of the following situations?
A) the 6-year-old with a broken arm from a trampoline injury B) the 14-year-old who attempts suicide C) the 4-year-old who still needs a diaper at night D) the 15-year-old who is pregnant; the father is a 17-year-old school friend
A patient's wound is showing signs of delayed healing. A nurse determines that the patient's diet may be the culprit and instructs the patient to eat more
1. Protein. 2. Vitamin B. 3. Vitamin D. 4. Fiber.
In the toxic triangle, the followers are
a. Conformers b. Colluders c. Constructivists d. Conscientious