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A novice nurse who will be assessing a patient after electroconvulsive therapy (ECT) asks her mentor, “What sort of memory impairment is present after several ECT treatments?” The best response for the mentor would be:
- A. “It’s hard to say. Treatment affects everyone differently.”
- B. “Usually the patient has severe difficulty remembering remote events.”
- C. “Patients have mild difficulty remembering recent events, like what waseaten for breakfast.”
- D. “Both recent and remote memory is affected, producing profound confused, cognitive
Correct Answer: D
Rationale: The correct answer is D because it accurately reflects the typical memory impairment after ECT treatments. ECT affects both recent and remote memory, leading to profound confusion and cognitive difficulties. This is due to the disruption of neural pathways involved in memory consolidation and retrieval.
Choice A is incorrect as ECT does have predictable effects on memory. Choice B is incorrect because patients typically have more difficulty with recent memory than remote memory. Choice C is also incorrect as patients usually experience more than just mild difficulty remembering recent events; the memory impairment is more severe than just forgetting what was eaten for breakfast.
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An elderly couple who lived in the same home for the past 50 years have moved into an
adult retirement center in a nearby town. Changes in lifestyle such as this couple is
experiencing should alert the nurse to the possibility of:
- A. Acute grief
- B. Traumatic grief
- C. Chronic sorrow
- D. Adventitious crisis
Correct Answer: D
Rationale: The correct answer is D: Adventitious crisis. This type of crisis is triggered by external events such as moving to a retirement center after 50 years in the same home. The sudden change in environment can lead to distress and challenges for the elderly couple, causing an adventitious crisis. Acute grief (A) and traumatic grief (B) are typically associated with the loss of a loved one, not a change in lifestyle. Chronic sorrow (C) refers to ongoing grief related to a chronic illness or disability, which is not the case in this scenario.
Which intervention should the nurse plan to reduce the patient's focus on delusional thinking?
- A. Confronting the delusion
- B. Refuting the delusion with logic
- C. Exploring reasons the patient has the delusion
- D. Focusing on feelings suggested by the delusion
Correct Answer: D
Rationale: The correct answer is D because focusing on the feelings suggested by the delusion can help the patient process and manage their emotions underlying the delusion. By addressing the emotions, the nurse can help the patient gain insight into the delusion and reduce its intensity. Confronting the delusion (A) may lead to resistance and reinforcement. Refuting the delusion with logic (B) may further alienate the patient. Exploring reasons for the delusion (C) may not directly address the emotional component.
The best response to the patient’s statement, "They frobitz me," would be:
- A. "That’s really too bad that you are being treated that way."
- B. "Who do you mean when you say everybody?"
- C. "What difference does frobitzing make?"
- D. "Why do they frobitz?"
Correct Answer: B
Rationale: The correct answer is B because it seeks clarification and prompts the patient to specify who they are referring to when they say "everybody." This response shows active listening and encourages deeper communication. Choice A offers sympathy but doesn't address the issue directly. Choice C dismisses the significance of "frobitzing." Choice D asks for the reason behind "frobitzing" without seeking clarification on the people involved.
The wife of a patient diagnosed with paranoid schizophrenia asks: “I’ve been told that my husband’s illness is probably related to imbalanced brain chemicals. Can you be more specific?”
- A. Breakdown of dopamine produces LSD, which in large amounts produces psychosis
- B. Decreased amounts of the brain chemical dopamine explain the presence of delusions and hallucinations.
- C. An increase in the brain chemical dopamine explains the presence of delusions and hallucinations.
- D. An increase in the brain chemical dopamine explains the presence of lack of motivation and disordered affect
Correct Answer: C
Rationale: The correct answer is C: An increase in the brain chemical dopamine explains the presence of delusions and hallucinations. In paranoid schizophrenia, there is an overactivity of dopamine receptors in the brain, leading to an excess of dopamine. This excess dopamine is associated with symptoms like delusions and hallucinations. Therefore, an increase in dopamine levels is directly linked to these specific symptoms in individuals with paranoid schizophrenia.
Explanation for why the other choices are incorrect:
A: Breakdown of dopamine producing LSD does not directly relate to the symptoms of paranoid schizophrenia.
B: Decreased amounts of dopamine do not explain the presence of delusions and hallucinations in paranoid schizophrenia; it is the increase in dopamine that is associated with these symptoms.
D: An increase in dopamine is more closely related to delusions and hallucinations rather than lack of motivation and disordered affect in paranoid schizophrenia.
A patient states, "I’m not worth anything. I have negative thoughts about myself. I feel anxious and shaky all the time. Sometimes I feel so sad that I want to go to sleep and never wake up." Which nursing intervention should have the highest priority?
- A. Self-esteem-building activities.
- B. Anxiety self-control measures.
- C. Sleep enhancement activities.
- D. Suicide precautions.
Correct Answer: D
Rationale: The correct answer is D: Suicide precautions. The patient's statement indicates they are experiencing severe depression and suicidal ideation. Suicide precautions should be the highest priority to ensure the patient's safety. This includes removing any potential means of self-harm, constant monitoring, and close supervision. Self-esteem-building activities (A) may be helpful in the long term but are not the immediate priority. Anxiety self-control measures (B) are important but addressing suicidal ideation takes precedence. Sleep enhancement activities (C) are also important but not the highest priority when dealing with suicidal thoughts.