A patient missed a treatment option. Later, the patient appears withdrawn and avoids eye contact when discussing calling loved ones. Which is the best nursing action?

The patient is demonstrating signs of ineffective coping and should be referred for psychiatric evaluation

The patient is showing symptoms of major depressive disorder and requires immediate intervention

The patient is noncompliant with medical care due to unresolved emotional issues

The patient is progressing through the normal stages of grief

Answer and Explanation

The Correct Answer is A

Choice A reason: Withdrawn behavior and avoiding eye contact suggest ineffective coping, as the patient struggles to process missing a treatment. Psychiatric evaluation can assess underlying emotional distress, such as anxiety or depression, and provide targeted interventions, making this the correct choice for addressing the patient’s needs.

Choice B reason: Symptoms like withdrawal could suggest depression, but diagnosing major depressive disorder requires more criteria, such as persistent low mood or anhedonia, not evident here. Immediate intervention assumes severity not supported by the scenario, making this choice less accurate than a referral.

Choice C reason: Labeling the patient as noncompliant assumes intentional refusal, but the scenario suggests emotional distress, not deliberate nonadherence. Withdrawal and avoidance indicate psychological barriers, not noncompliance, making this choice incorrect for the described behavior.

Choice D reason: Normal grief involves stages like denial or sadness, but the scenario lacks evidence of a loss triggering grief. Withdrawal and avoidance suggest coping difficulties, not a clear grief process, making this choice incorrect for the patient’s presentation.

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Correct Answer is D

Explanation

Choice A reason: The Durham Rule holds that a defendant is not criminally responsible if their act was a product of mental disease. It is broad and does not specifically address the inability to control behavior despite knowing wrongfulness, making it less applicable than irresistible impulse.

Choice B reason: The M’Naghten Rule focuses on a defendant’s inability to understand the nature or wrongfulness of their actions due to mental illness. The scenario emphasizes inability to control behavior, not lack of understanding, making this choice incorrect.

Choice C reason: The Tarasoff Rule requires clinicians to warn potential victims of a patient’s threat, unrelated to insanity defenses. It addresses duty to protect, not the legal standard for criminal responsibility, making this choice irrelevant to the scenario.

Choice D reason: The irresistible impulse standard applies when a defendant understands their actions were wrong but cannot control their behavior due to mental illness. This matches the scenario, where the patient’s inability to control actions led to the insanity ruling, making this the correct choice.

A. Maintaining limbs in a fixed position B. Repetitive, purposeless movements like rocking or pacing C. Rapid, involuntary muscle jerks or spasms D. Resistance to passive movement followed by a sudden release

Correct Answer is A

Explanation

Choice A reason: Waxy flexibility, seen in catatonia, involves patients maintaining limbs in fixed positions when placed there, reflecting basal ganglia and prefrontal cortex dysfunction. This passive rigidity is a hallmark of catatonic schizophrenia or mood disorders, making this the correct choice.

Choice B reason: Repetitive, purposeless movements like rocking are stereotypic behaviors, often in autism or anxiety disorders. These active movements differ from the passive, fixed posturing of waxy flexibility in catatonia, making this choice incorrect.

Choice C reason: Rapid, involuntary muscle jerks or spasms are extrapyramidal symptoms, often from antipsychotics affecting dopamine pathways. These are distinct from the sustained, passive limb positioning in waxy flexibility, making this choice incorrect for the described phenomenon.

Choice D reason: Resistance to passive movement followed by release describes cogwheel rigidity, seen in Parkinson’s disease, due to dopamine deficits. Waxy flexibility involves sustained positioning without resistance, making this choice incorrect for the catatonic feature described.

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A patient missed a treatment option. Later, the patient appears withdrawn and avoids eye contact when discussing calling loved ones. Which is the best nursing action?

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

What is waxy flexibility in psychiatric patients?

Correct Answer is A

Explanation

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A patient missed a treatment option. Later, the patient appears withdrawn and avoids eye contact when discussing calling loved ones. Which is the best nursing action?