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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.
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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.
A woman whose abusive husband was killed in an automobile accident 3 years earlier continues to idealize him and repeatedly talks about their “wonderful relationship.” Which outcome is most appropriate for the patient? Patient will:
- A. Enlist the emotional support of both family and friends.
- B. Keep a daily journal recording memories of time spent with her husband.
- C. Express both positive and negative feelings about her husband and their life together.
- D. Read information on the affects of physical abuse and the support groups available to her.
Correct Answer: C
Rationale: Rationale:
Choice C is correct because it encourages the patient to express both positive and negative feelings about her husband and their relationship. This approach helps the patient process complex emotions and move towards a more realistic view of the past. It promotes emotional healing and growth by allowing the patient to acknowledge and work through conflicting feelings.
Summary of Incorrect Choices:
A: While emotional support is important, simply enlisting the support of family and friends may not address the underlying issues of idealization and unresolved emotions.
B: Keeping a daily journal may reinforce the idealization of the husband and could potentially hinder the patient's progress in coming to terms with the reality of the relationship.
D: Reading about abuse and support groups may provide information, but it does not directly address the patient's need to explore and express her own feelings about her husband and their relationship.
When a patient asks the nurse, “How can jolting me with an electrical shock possibly do me any good?” the answer most reflective of current biologic theory would be:
- A. “ECT produces a change in brain chemistry that results in improved mood.
- B. “ECT provides you with external punishment so you can stop punishing yourself.”
- C. “ECT interrupts brain impulses that are causing hallucinations and delusions.”
- D. ECT shocks the brain into re-establishing normal electrical patterns.”
Correct Answer: A
Rationale: Step 1: Electroconvulsive therapy (ECT) is a treatment for severe depression and other mental health disorders.
Step 2: Current biological theory suggests that ECT produces changes in brain chemistry, specifically neurotransmitters, leading to improved mood.
Step 3: The correct answer (A) aligns with this theory by explaining how ECT impacts brain chemistry to alleviate symptoms.
Step 4: Answer B is incorrect as ECT is not used as punishment but as a therapeutic intervention.
Step 5: Answer C is incorrect as ECT is not primarily used to interrupt brain impulses causing hallucinations and delusions.
Step 6: Answer D is incorrect as ECT does not shock the brain into re-establishing normal electrical patterns but rather affects neurotransmitter levels.
A young woman had just learned of the accidental death of her husband. She begins to cry
and states, Its not fair! How could he do this to me? This remark is assessed as:
- A. A plea for help
- B. An explosive episode
- C. An expression of anger
- D. Fear of making decisions alone
Correct Answer: C
Rationale: The correct answer is C, an expression of anger. The woman's statement "It's not fair! How could he do this to me?" indicates feelings of anger and resentment towards her husband for leaving her unexpectedly. This response does not show a plea for help (A), as she is expressing her emotions rather than seeking assistance. It is also not an explosive episode (B) as there is no indication of sudden outbursts or intense emotional reactions. Similarly, it is not about fear of making decisions alone (D) as her statement focuses on her feelings of unfairness and betrayal. In summary, the woman's remark reflects her anger and sense of injustice following her husband's accidental death.
When differentiating between bereavement symptoms and depression, the nurse will base the formulation on knowledge that in bereavement:
- A. Symptoms remit and exacerbate.
- B. Guilt feelings are overwhelming.
- C. Suicide thoughts are common.
- D. Psychomotor retardation is obvious.
Correct Answer: A
Rationale: The correct answer is A because in bereavement, symptoms of grief and sadness tend to come and go, known as remitting and exacerbating, as the individual processes the loss over time. This is a normal part of the grieving process. On the other hand, in depression, symptoms are persistent and may not improve without intervention. Guilt feelings being overwhelming (B) is common in both bereavement and depression. Suicide thoughts being common (C) can occur in severe depression but are not a distinguishing factor between bereavement and depression. Psychomotor retardation being obvious (D) is a symptom more commonly associated with severe depression rather than bereavement.