Nokea
A 75-year-old patient comes to the clinic reporting frequent headaches. As the nurse begins the interaction, which action is most important?
- A. Complete a neurological assessment
- B. Determine whether the patient can hear as the nurse speaks
- C. Suggest that the patient lie down in a darkened room for a few minutes
- D. Administer medication to relieve the patient's pain before continuing the assessment
Correct Answer: B
Rationale: Correct Answer: B. Determine whether the patient can hear as the nurse speaks.
Rationale:
1. Hearing assessment is crucial to ensure patient understanding and communication.
2. Hearing loss may affect compliance with treatment and safety.
3. Identifying hearing deficits early can prevent misunderstandings and improve patient outcomes.
Summary:
- A: While a neurological assessment may be necessary, addressing hearing first is more immediate.
- C: Suggesting rest may help with headache management, but addressing hearing is more critical.
- D: Administering medication is premature without assessing hearing first.
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A nurse would conclude that a patient with an eating disorder is exhibiting a cognitive distortion after hearing the patient make which statement?
- A. I see now that I need to establish my own preferences and routines.'
- B. Bingeing makes my feelings of both isolation and loneliness go away.'
- C. Controlling what I eat has been a way for me to exert control over my life.'
- D. I need to watch for hunger and fatigue as triggers for my eating disorder.'
Correct Answer: B
Rationale: The correct answer is B because the statement reflects emotional reasoning, a common cognitive distortion in eating disorders. The patient believes that bingeing is an effective way to cope with feelings of isolation and loneliness, which is not a healthy or rational belief. This cognitive distortion can perpetuate the cycle of disordered eating behavior.
A: This choice shows a healthy realization and decision-making process, indicating a positive step towards recovery.
C: While controlling food intake may be a coping mechanism, it doesn't necessarily indicate a cognitive distortion.
D: This choice demonstrates awareness of triggers, which is important for managing the disorder, but it doesn't necessarily indicate a cognitive distortion.
A client has been admitted with disorganized type schizophrenia. The nurse observes blunted affect and social isolation. The client occasionally curses or calls another client a 'jerk' without provocation. The nurse asks the client how he is feeling, and he responds, 'Everybody picks on me. They frobitz me.' The best response for the nurse to make would be:
- A. That's really too bad.'
- 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: "Who do you mean when you say 'everybody'?"
Rationale:
1. Clarifying the client's statement helps to understand his perception.
2. Asking specifically about 'everybody' encourages the client to express his feelings and thoughts.
3. It promotes therapeutic communication by showing empathy and active listening.
Incorrect choices:
A: "That's really too bad." - This response does not address the client's specific concerns or promote further exploration.
C: "What difference does frobitzing make?" - This response is dismissive and lacks empathy or understanding of the client's experience.
D: "Why do they frobitz?" - This response is confrontational and may come across as accusatory, potentially shutting down communication.
A nurse planning a group to help batterers learn more effective ways to cope would teach participants that the key component in wife battering is:
- A. The need for the batterer to control
- B. Alcohol abuse by the batterer
- C. History of psychotic behavior
- D. Failure of the woman to assert herself
Correct Answer: A
Rationale: The correct answer is A: The need for the batterer to control. This is the key component in wife battering, as it is rooted in the batterer's desire to establish power and dominance over their partner. Teaching batterers more effective ways to cope involves addressing this underlying need for control.
Explanation of other choices:
B: Alcohol abuse by the batterer - While alcohol abuse may exacerbate violent behavior, it is not the primary cause of wife battering.
C: History of psychotic behavior - Psychotic behavior may contribute to violence, but it is not the key component in wife battering.
D: Failure of the woman to assert herself - Blaming the victim is not appropriate; the responsibility lies with the batterer's need for control.
Adolescents often cite barriers for discussing psychosocial issues with their physician. If confidentiality is addressed, which of the following do adolescents NOT cite as a barrier:
- A. Non-judgemental approach of physician
- B. Personal embarrassment towards discussing sensitive topics
- C. Physician seems rushed
- D. Physician did not ask about sensitive topics
Correct Answer: A
Rationale: A non-judgmental approach facilitates discussion and is not a barrier, unlike embarrassment, time constraints, or perceived lack of understanding.
The client tells the nurse, 'My husband left to go bowling with his buddies, so I had to cut myself.' The nurse using the SET method of communication will use as the initial response:
- A. Tell me what made you think of that action.'
- B. It concerns me to hear that you took that action.'
- C. You should have called your psychiatrist.'
- D. What can I do to help you now that you're here?'
Correct Answer: B
Rationale: The correct answer is B: "It concerns me to hear that you took that action." The rationale for this is that this response demonstrates empathy and concern for the client's well-being, which is essential in building a therapeutic relationship. It acknowledges the client's statement without judgment and opens the door for further exploration of the client's feelings and reasoning behind the self-harm.
Choice A: "Tell me what made you think of that action" may come across as too direct and could be perceived as insensitive or confrontational, potentially shutting down communication.
Choice C: "You should have called your psychiatrist" is dismissive and fails to address the client's emotional needs or offer support.
Choice D: "What can I do to help you now that you're here?" is forward-thinking and assumes the client is seeking help, which may not be the case. It also does not directly address the concerning behavior of self-harm.