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 patient was abducted and raped at gunpoint by an unknown assailant. Which nursing interventions are appropriate while caring for the patient in the emergency department? Select all that apply.
- A. Allow the patient to talk at a comfortable pace.
- B. Place the patient in a private room with a caregiver.
- C. Pose questions in nonjudgmental, empathetic ways.
- D. None of the above.
Correct Answer: A
Rationale: The correct answer is A: Allow the patient to talk at a comfortable pace. This intervention is appropriate because it promotes the patient's autonomy and empowerment in sharing their experience, which can be therapeutic. It also helps establish trust and rapport, facilitating effective communication and assessment.
Incorrect choices:
B: Placing the patient in a private room with a caregiver can be important for privacy and support but may not be the immediate priority.
C: Posing questions in nonjudgmental, empathetic ways is crucial but may not be as important as allowing the patient to talk at their own pace initially.
D: None of the above is incorrect as allowing the patient to talk is a crucial step in providing appropriate care for a patient who has experienced trauma.
CT scans of the brains of some young schizophrenics show than normal
- A. wider ventricles
- B. smaller fissures
- C. smaller ventricles
- D. fewer fissures
Correct Answer: A
Rationale: Enlarged ventricles in schizophrenics suggest brain abnormalities linked to the disorder.
A patient with swelling and a laceration above the right eye states, 'I don't know what caused me to fall and cut my head on the door frame in my bedroom. I'm lucky my spouse was home to take me to the hospital.' The patient's spouse appears nervous but smiles when mentioning that the patient is 'so clumsy at times.' Which nursing intervention should the nurse give priority attention to when addressing this patient's needs?
- A. Provide a thorough assessment that includes a focus on signs of old injuries.
- B. Interview the patient regarding the circumstances surrounding this suspicious fall.
- C. Directly ask the patient if spousal abuse is occurring or has ever occurred.
- D. Notify security that there is a possibility that this patient is a victim of physical abuse.
Correct Answer: A
Rationale: The correct answer is A: Provide a thorough assessment that includes a focus on signs of old injuries. This is the priority intervention because the patient's statement, combined with the spouse's behavior, raises suspicion of potential domestic abuse. By assessing for signs of old injuries, the nurse can gather crucial information to determine if the patient is a victim of abuse.
Choice B: Interview the patient regarding the circumstances surrounding this suspicious fall may be important, but assessing for signs of old injuries takes priority as it provides concrete evidence of potential abuse.
Choice C: Directly ask the patient if spousal abuse is occurring or has ever occurred is necessary, but the patient may not feel comfortable disclosing abuse directly. Assessing for old injuries can provide objective evidence.
Choice D: Notify security that there is a possibility that this patient is a victim of physical abuse is premature without concrete evidence. Assessing for old injuries should be done first to gather information before taking further action.
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.
The expected outcome for a patient with a nursing diagnosis of disturbed thought processes is:
- A. The patient will be safe from injury.
- B. The patient will meet basic biological needs.
- C. The patient will achieve optimum cognitive functioning.
- D. The patient will maintain positive interpersonal relationships.
Correct Answer: C
Rationale: The correct answer is C because disturbed thought processes indicate cognitive impairment. Thus, the expected outcome should focus on improving cognitive functioning to achieve optimal mental clarity and decision-making. Safety (A) is important but not directly related to cognitive improvement. Meeting basic needs (B) and maintaining relationships (D) are important but not the primary focus when the diagnosis is disturbed thought processes. So, the priority is on enhancing cognitive functioning to address the root cause of the issue.