Nokea
A 79-year-old white male tells a nurse, 'I have felt very sad lately. I do not have much to live for. My family and friends are all dead, and my own health is failing.' The nurse should analyze this comment as
- A. normal pessimism of the elderly.
- B. evidence of risks for suicide.
- C. a call for sympathy.
- D. normal grieving.
Correct Answer: B
Rationale: The correct answer is B: evidence of risks for suicide. The elderly man's statement indicates feelings of hopelessness, loneliness, and lack of purpose, which are common risk factors for suicide in older adults. The nurse should assess further for suicidal ideation and intervene accordingly.
Choice A is incorrect because the statement goes beyond normal pessimism by expressing thoughts of not having much to live for. Choice C is incorrect as the statement is more indicative of distress rather than a mere call for sympathy. Choice D is incorrect as normal grieving typically involves processing emotions related to a specific loss, whereas the man's statement reflects a broader sense of despair.
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A child, age 5, was admitted to the children's unit, having been sexually abused by an acquaintance of her family. The child refuses to talk and participate in unit activities, choosing to stay in her room with her stuffed animals. Which therapeutic intervention will best help the child release pent-up feelings about the abuse?
- A. Individual communication with the nurse
- B. Play therapy
- C. Family therapy
- D. Role-play with other children on the unit
Correct Answer: B
Rationale: The correct answer is B: Play therapy. Play therapy is the most suitable therapeutic intervention for a child in this scenario because it allows the child to express their feelings and experiences through play, which is a natural form of communication for children. Through play therapy, the child can act out their experiences using toys and create a safe space to process their emotions without having to verbally communicate. It helps the child release pent-up feelings and trauma in a non-threatening environment.
Summary of other choices:
A: Individual communication with the nurse may not be as effective as play therapy in this case as the child is not yet comfortable verbalizing their feelings.
C: Family therapy may not be appropriate at this stage as the child is not ready to engage with family members about the abuse.
D: Role-play with other children on the unit may not be beneficial as it can potentially trigger more anxiety and discomfort for the abused child.
An outpatient diagnosed with schizophrenia attends programming at a community mental health center. The patient says, I threw away the pills because they keep me from hearing God. Which response by the nurse would most likely to benefit this patient?
- A. You need your medicine. Your schizophrenia will get worse without it.
- B. Do you want to be hospitalized again? You must take your medication.
- C. I would like you to come to the medication education group every Thursday.
- D. I noticed that when you take the medicine, you have been able to hold a job you wanted.
Correct Answer: D
Rationale: Connecting medication to the patient's goal (job) (D) motivates adherence despite desirable hallucinations. Exhortations (A, B) ignore insight issues, and education (C) assumes a knowledge deficit, not the core problem.
Which stage of Piaget's theory marks the onset of logical thinking?
- A. Sensorimotor
- B. Preoperational
- C. Concrete Operational
- D. Formal Operational
Correct Answer: C
Rationale: The Concrete Operational stage (C), around age 7-11, marks the onset of logical thinking about concrete events, per Piaget's theory. Earlier stages (A, B) lack this, and Formal Operational (D) involves abstract logic later.
Major concerns of the elderly living alone in their home are: (Name 1)
- A. Safety
- B. Quality of life
- C. Support system
- D. Access to medical care
Correct Answer: A
Rationale: Safety (A) is a major concern for the elderly living alone, as it impacts their ability to remain independent and healthy. Other concerns like quality of life (B), support system (C), and medical access (D) are also relevant but asked as a single choice here.
What is the most important aspect of nursing care for patients with anorexia nervosa during refeeding?
- A. Refeed the patient with high-calorie foods quickly to gain weight.
- B. Start with small, manageable portions and gradually increase caloric intake.
- C. Restrict food choices to healthy foods only.
- D. Encourage the patient to take food supplements in addition to meals.
Correct Answer: B
Rationale: The correct answer is B: Start with small, manageable portions and gradually increase caloric intake. This approach is essential because refeeding syndrome can occur in patients with anorexia nervosa, where rapid refeeding can lead to severe electrolyte imbalances and potentially life-threatening complications. Starting with small portions helps to prevent this syndrome by allowing the body to gradually adjust to increased caloric intake. Additionally, it helps in preventing overwhelming the patient with large amounts of food, which can trigger anxiety and resistance to eating.
Incorrect choices:
A: Refeed the patient with high-calorie foods quickly to gain weight - This can lead to refeeding syndrome and is not a safe approach.
C: Restrict food choices to healthy foods only - Restricting food choices can exacerbate disordered eating behaviors and does not address the need for gradual refeeding.
D: Encourage the patient to take food supplements in addition to meals - While supplements can be helpful, they should not be a primary focus over balanced