Nokea
Which statement made by a teenage male hospitalized after a failed suicide attempt is most concerning to the nurse?
- A. The gun I got for my birthday is my most prized possession.
- B. I don’t know why I get so depressed and want to die.
- C. "I don’t feel like I can talk to anyone about my feelings."
- D. The gun I got for my birthday is my most prized possession.
Correct Answer: D
Rationale: This statement is concerning because it suggests the teenager may still have access to dangerous means (in this case, a gun) and may not fully understand or take responsibility for the gravity of his previous suicidal attempt. The attachment to the gun is alarming.
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The patient and the nurse have agreed on problems to be addressed during a short course of outpatient therapy. At the beginning of the appointment, the patient states, “I’d like to work on the issue of relationships today.” Which assessment can be made?
- A. The nurse should suggest several alternative behaviors.
- B. The patient must be able to manage emotions before continuing.
- C. The relationship is moving from orientation to working phase.
Correct Answer: C
Rationale: The correct assessment to be made in this scenario is that the relationship is moving from the orientation phase to the working phase. In the orientation phase of the nurse-patient therapeutic relationship, the focus is on building rapport, establishing trust, and determining the patient's needs and goals. As the patient voluntarily expresses a desire to work on the issue of relationships, it indicates a transition to the working phase where the patient actively identifies problems to address and goals to achieve. This shift demonstrates progress in the therapeutic relationship as the patient is engaging in the therapeutic process and contributing to the agenda set for the appointment. It signifies a readiness for collaborative problem solving and intervention planning, emphasizing the importance of the patient's involvement in decision-making and goal-setting in the therapeutic process.
In the ECT treatment preparation period the morning of treatment, the nurse should:
- A. Assess the patient’s cognitive function.
- B. Have the patient exercise for 10 minutes.
- C. Ensure that the patient produces a urine sample.
- D. Allow the patient to eat a heavy meal if they are hungry.
Correct Answer: A
Rationale: The correct action during the ECT treatment preparation period the morning of treatment is to adequately hydrate the patient. Ensuring that the patient is properly hydrated before the procedure is crucial for their safety and well-being. Hydration helps optimize the effects of the treatment and can support the patient's recovery post-treatment. It is important to maintain the patient's fluid balance as ECT can sometimes cause side effects such as nausea, headache, and muscle aches, which can be worsened if the patient is not adequately hydrated. Additionally, hydration can help prevent complications such as dehydration or electrolyte imbalances during and after the ECT procedure.
A patient is experiencing distress with midlife transition. Which statement provides support that the patient is successfully managing this stressor?
- A. “I won’t give up on my dream to be rich.”
- B. “I wasn’t being realistic when I set being rich as my life’s goal.”
- C. “I’ll never be rich, but I can save enough to live comfortably.”
- D. “Being rich doesn’t necessarily make a person happy.”
Correct Answer: C
Rationale: Successfully managing midlife transitions involves finding realistic and satisfying alternatives to earlier, unmet goals, demonstrating emotional growth and adaptability.
When differentiating between bereavement symptoms and depression, the nurse will base the formulation on knowledge that in bereavement:
- A. Suicide thoughts are common.
- B. Symptoms remit and exacerbate.
- C. Guilt feelings are overwhelming.
- D. Psychomotor retardation is obvious.
Correct Answer: B
Rationale: Bereavement involves waves of emotional pain, often triggered by reminders of the loss, whereas depression typically causes persistent symptoms such as guilt or hopelessness.
An elderly patient must be physically restrained. Who is responsible for the patient's safety?
- A. Unlicensed assistive personnel who apply the restraint
- B. Family member who agrees to the application of the restraint
- C. The nurse assigned to care for the patient.
- D. Health care provider who prescribed the application of restraint
Correct Answer: C
Rationale: The nurse is responsible for the patient’s safety, including the appropriate use of restraints and ensuring the patient is monitored appropriately. The nurse is accountable for assessing the need for restraints, their proper application, and ongoing evaluation of the patient’s condition while restrained