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A 16-year-old female patient who is Chinese American is admitted to the unit with reports of sadness and suicidal ideation. The patient is accompanied by many family members, including her mother and father. The patient and her family emigrated from mainland China five years ago. Regarding the family, the psychiatric-mental health nurse:
- A. encourages the patient to communicate her need for privacy to her family
- B. gently asks the family members to leave the room
- C. privately asks the mother for her assistance in clearing the room
- D. provides care for the patient while the family members are present
Correct Answer: C
Rationale: Involving the mother respects cultural family dynamics while facilitating a private assessment, balancing sensitivity and need.
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Which statement by a patient with borderline personality disorder best indicates the treatment plan is helping?
- A. I think you are the best nurse on the unit.'
- B. I hate my doctor. He never gives me what I ask for.'
- C. I feel empty and want to cut myself, so I called you.'
- D. I'm never going to get high on drugs again.'
Correct Answer: C
Rationale: The correct answer is C. This statement indicates progress because the patient is demonstrating insight into their emotions, seeking help, and utilizing a coping strategy by reaching out for support instead of engaging in self-harm. Choice A does not provide information about progress in treatment. Choice B reflects a negative attitude towards the doctor. Choice D does not offer any insight into the patient's emotional state or progress in managing their behaviors.
A patient diagnosed with schizophrenia reveals to the nurse that voices have warned of danger and adds, 'They're so loud they frighten me. Do you hear them?' The nurse's best initial response would be:
- A. I know these voices are very real to you, but I don't hear them.'
- B. Don't worry. You're safe in the hospital. I won't let anything happen to you.'
- C. Tell me more about the voices. Are they men or women? How many are there?'
- D. What do you do in order to keep yourself occupied so you don't hear the voices?'
Correct Answer: A
Rationale: The correct answer is A because it acknowledges the patient's experience without dismissing or invalidating it. By stating, "I know these voices are very real to you, but I don't hear them," the nurse validates the patient's reality and expresses empathy. This response helps build trust and rapport, which is crucial in establishing a therapeutic relationship.
Choice B is incorrect because it dismisses the patient's concerns and offers false reassurance, which may not be effective in addressing the patient's distress.
Choice C is incorrect as it focuses on gathering more information about the voices without addressing the patient's immediate emotional distress.
Choice D is incorrect because it shifts the focus away from the patient's current experience and onto distractions, which may not be helpful in addressing the patient's distressing symptoms.
The priority nursing focus for the period immediately after electroconvulsive therapy treatment should be on:
- A. Monitoring for the return of the capacity for full range of motion.
- B. Assessing the degree of accumulating memory impairment.
- C. Making positive comments while the patient is more receptive.
- D. Assessing the level of consciousness and normal body functions.
Correct Answer: D
Rationale: The correct answer is D: Assessing the level of consciousness and normal body functions. After electroconvulsive therapy (ECT), it is crucial to monitor the patient's level of consciousness and ensure all body functions are normal to detect any potential complications immediately. This includes assessing vital signs, neurological status, respiratory function, and cardiovascular stability. Monitoring for the return of full range of motion (A) is not a priority immediately post-ECT. Assessing memory impairment (B) may be important but is not the immediate priority. Making positive comments (C) is helpful for emotional support but does not address the critical need to assess physical status.
Which assessment data suggests a person who appears to have dementia instead has depression and pseudodementia?
- A. Demonstrates impaired judgment.
- B. Demonstrates impaired concentration.
- C. Has a history of significant losses or crises.
- D. None of the above.
Correct Answer: B
Rationale: The correct answer is B because impaired concentration is a key indicator of depression and pseudodementia rather than dementia. In depression, individuals may experience difficulties focusing and maintaining attention, leading to impaired concentration. Pseudodementia, which mimics dementia but is caused by depression, also presents with similar cognitive symptoms like impaired concentration. Choices A and C are incorrect because impaired judgment and significant losses or crises can be present in both dementia and depression, making them less specific to differentiating between the two conditions. Choice D is incorrect as choice B clearly distinguishes the cognitive symptomatology between dementia and depression/pseudodementia.
While planning care for a preschool child who has been physically and sexually abused, the nurse includes play therapy because it assists the child to:
- A. Act out aggression in an acceptable manner
- B. Express feelings that cannot easily be verbalized
- C. Interact with other children in the appropriate age group
- D. Learn adaptive behaviors through acting
Correct Answer: B
Rationale: The correct answer is B: Express feelings that cannot easily be verbalized. Play therapy allows preschool children to express their emotions, trauma, and experiences through play activities, as they may not have the verbal skills to communicate their feelings effectively. This form of therapy helps the child process their emotions and experiences in a safe and non-threatening environment.
Incorrect Choices:
A: Acting out aggression in an acceptable manner is not the primary goal of play therapy for abused children. It is more about emotional expression and healing.
C: Interacting with other children in the appropriate age group is not the focus of play therapy for abused children. The primary goal is to address the trauma and emotional distress.
D: Learning adaptive behaviors through acting is not the main purpose of play therapy for abused children. It is more about emotional healing and expression.