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 patient describes loss of significant others, economic security, and health. He describes mood alteration and voices the thought that he has little to live for. Combined with his age, sex, and single status, each is a risk factor for suicide. Elderly white males have the highest risk for completed suicide.
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A client who has been diagnosed as having paranoid schizophrenia is highly suspicious and delusional. He hears voices telling him terrorists are plotting to assassinate him. He refuses to eat, saying the food is poisoned. The nursing action that best addresses his needs is to:
- A. Explain that others eat the food and are not harmed
- B. Allow client to select food from vending machines
- C. Assist client with personal hygiene and grooming
- D. Not allow client to verbalize delusional thoughts
Correct Answer: B
Rationale: The correct answer is B: Allow client to select food from vending machines. This option respects the client's autonomy and addresses his delusion about the food being poisoned. By allowing the client to choose food from vending machines, it acknowledges his concerns and promotes a sense of control over his environment. This approach can help build trust and rapport with the client, as forcing him to eat regular hospital food might exacerbate his paranoia and resistance.
A: Explaining that others eat the food and are not harmed may not be effective as it disregards the client's beliefs and could further alienate him.
C: Assisting with personal hygiene and grooming is important but does not directly address the client's primary concern of refusing to eat due to delusional beliefs.
D: Not allowing the client to verbalize delusional thoughts is counterproductive as it suppresses communication and does not address the underlying issue of the client's fear of being poisoned.
A patient with an eating disorder states, 'I heard people laughing behind me in the check-out line at the department store. I bet they thought it was hysterically funny that I gained a pound in the last few days.' The nurse documents that the patient is exhibiting which cognitive distortion related to maladaptive eating regulation responses?
- A. Magnification
- B. Personalization
- C. Overgeneralization
- D. Dichotomous thinking
Correct Answer: B
Rationale: The correct answer is B: Personalization. Personalization is a cognitive distortion where an individual attributes external events to themselves without any evidence. In this case, the patient is assuming that people laughing were directed at them and related to their weight gain, which is a distorted belief.
A: Magnification involves blowing things out of proportion, which is not evident in this scenario.
C: Overgeneralization involves drawing broad conclusions based on a single incident, which is not happening here.
D: Dichotomous thinking involves seeing things in black and white terms, which is not demonstrated in the patient's statement.
In summary, the patient's attribution of others' laughter to their weight gain without evidence aligns with the cognitive distortion of personalization, making it the correct choice.
The nurse who sees a number of battered women each year decides to put together a set of guidelines for nurses. An appropriate guideline to include, with the victims' informed consent, would be to:
- A. Take at least two photographs of each trauma area
- B. Assess for sexually transmitted disease
- C. Follow rape protocol even when rape is not suspected
- D. Make protective services aware of the abuse
Correct Answer: A
Rationale: The correct answer is A because taking photographs of trauma areas can provide crucial evidence for legal and medical purposes. It can help document the extent of injuries and aid in the prosecution of the abuser. This step is essential in ensuring proper documentation and care for the victims.
Option B is incorrect because assessing for sexually transmitted diseases may not be the immediate priority in cases of domestic violence. Option C is incorrect as following rape protocol when rape is not suspected may not be necessary and could potentially retraumatize the victim. Option D is incorrect because making protective services aware of the abuse should only be done with the victim's consent to ensure their safety and autonomy.
Which of these assessment findings would indicate that a rape victim is exhibiting behavior typically seen in the acute stage of sexual assault?
- A. Patient is very demanding and controlling in manner when dealing with staff.
- B. Patient appears to be confused, restless, and fearful when left alone.
- C. Patient uses profanity to describe the events surrounding the attack.
- D. Patient experiences a panic attack on the anniversary of the attack.
Correct Answer: B
Rationale: The correct answer is B because exhibiting confusion, restlessness, and fear when left alone aligns with the acute stage of sexual assault trauma. During this stage, victims often experience shock, disbelief, and heightened anxiety. This behavior reflects immediate emotional distress and trauma response. Choice A indicates characteristics of control and demanding behavior, which are not typically seen in the acute stage. Choice C suggests using profanity, which may vary based on individual coping mechanisms. Choice D indicates a specific trigger response on the anniversary, suggesting a later stage of processing trauma, not the acute phase.
The nurse in the emergency department tells the daughter of a patient that her 86-year-old mother has had a stroke. The daughter tearfully asks the nurse, 'Who will take care of me now?' When the nurse explores this query, the daughter mentions that her mother always tells her what job to take, what clothes to buy and wear, and what to have for lunch. The daughter states that she needs someone to direct her and reassure her when she gets anxious. With which personality disorder is this presentation most consistent?
- A. Histrionic
- B. Dependent
- C. Narcissistic
- D. Borderline
Correct Answer: B
Rationale: The correct answer is B: Dependent. This presentation is most consistent with dependent personality disorder because the daughter is displaying excessive need for someone to take care of her and make decisions for her, as well as seeking reassurance and guidance when anxious. Individuals with dependent personality disorder often lack self-confidence and rely heavily on others for emotional and physical needs.
Choice A: Histrionic personality disorder is characterized by attention-seeking behavior and excessive emotions, which do not match the daughter's presentation.
Choice C: Narcissistic personality disorder involves a grandiose sense of self-importance and a lack of empathy for others, which is not evident in the daughter's behavior.
Choice D: Borderline personality disorder is characterized by unstable relationships, self-image, and emotions, as well as impulsive behaviors, which are not reflected in the daughter's need for constant direction and reassurance.