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. A call for sympathy
- C. Evidence of risks for suicide.
- D. Normal grieving.
Correct Answer: C
Rationale: The correct answer is C: Evidence of risks for suicide. The statement contains indicators such as feeling very sad, lack of purpose, isolation, and declining health, which are red flags for suicide risk in older adults. It is crucial for healthcare providers to assess and intervene promptly in such cases to prevent harm. Choices A, B, and D are incorrect because they do not address the seriousness of the situation or the potential risk for self-harm.
You may also like to solve these questions
Which intervention will the nurse planning care for a patient with acute grief implement?a. Providing information about the grief process
- A. Providing information about the grief process.
- B. Suggesting utilization of community resources in a few weeks
- C. Encouraging dependence on the nurse for support
- D. Assessing for signs of complicated grief or depression
Correct Answer: A
Rationale: The correct answer is A because providing information about the grief process helps the patient understand their feelings and reactions, promoting emotional healing. Choice B is incorrect because suggesting community resources may not address the patient's immediate needs. Choice C is incorrect as encouraging dependence on the nurse may hinder the patient's ability to cope independently. Choice D is incorrect because assessing for complicated grief or depression is important but not the initial intervention in planning care for acute grief.
The nurse determines that a patient is showing a decline in explicit memory. Which characterizes such a deficiency?
- A. Inability to remember how to operate a common kitchen appliance
- B. Difficulty remembering the name of a place visited 20 years ago
- C. Being unsuccessful at retaining new information
- D. Forgetting the ingredients of a favorite recipe
Correct Answer: B
Rationale: The correct answer is B because difficulty remembering the name of a place visited 20 years ago is a specific example of explicit memory decline. Explicit memory refers to the ability to consciously recall past events, facts, or experiences. This choice directly relates to a long-term memory retrieval issue, which is a hallmark of explicit memory decline. Choices A, C, and D do not specifically address explicit memory decline but rather touch on different memory processes such as procedural memory (A), short-term memory (C), and semantic memory (D).
An adult patient shares that, When my mother died when we were children, I never saw my
father show any emotion. What do you think will happen with those unexpressed feelings?
Which response is most appropriate?
- A. Pent-up emotions may lead to depression or other disorders.
- B. Your father probably has worked through his grief by this time.
- C. Maybe you can teach him how to best express his own feelings.
- D. If feelings are not effectively expressed, the person can become suicidal.
Correct Answer: A
Rationale: Step 1: Pent-up emotions are emotions that are suppressed or not expressed.
Step 2: Unexpressed feelings, especially from past traumatic events, can lead to emotional distress.
Step 3: Long-term suppression can manifest as depression or other mental health disorders.
Step 4: Therefore, choice A is the most appropriate response as it highlights the potential negative consequences of unexpressed emotions.
Summary:
- Choice B assumes the father has processed his grief, which may not be the case.
- Choice C oversimplifies the complexity of emotional expression and may not address the root issue.
- Choice D jumps to an extreme outcome without considering the range of possible consequences.
Immediately after electroconvulsive therapy (ECT), nursing care of the patient is most similar to care of a patient:
- A. With delirium tremens
- B. Recovering from conscious sedation
- C. With acute alcohol withdrawal
- D. Undergoing a routine diagnostic procedure
Correct Answer: B
Rationale: The correct answer is B: Recovering from conscious sedation. After ECT, patients are closely monitored as they recover from anesthesia and sedation. Nursing care involves assessing vital signs, mental status, and ensuring the patient's safety. This is similar to caring for a patient recovering from conscious sedation, where monitoring and observation are essential.
A: Delirium tremens involves severe alcohol withdrawal symptoms, which require specialized care including managing agitation and hallucinations.
C: Acute alcohol withdrawal requires specific interventions such as monitoring for seizures and providing medications to prevent complications.
D: Routine diagnostic procedures do not typically involve sedation or anesthesia, so the level of monitoring and care needed is different from post-ECT care.
Which action will best facilitate the development of trust between a nurse and patient?
- A. Responding positively to the patient’s demands
- B. Clarifying with the patient whenever there is doubt
- C. Staying available to the patient for the entire shift
- D. Following through with whatever was promised
Correct Answer: B
Rationale: The correct answer is B, clarifying with the patient whenever there is doubt. This action shows active listening, respect, and a willingness to understand the patient's needs. By seeking clarification, the nurse demonstrates genuine interest in the patient's perspective, which helps build trust. Responding positively to demands (A) may not always be appropriate or feasible. Staying available for the entire shift (C) is important but not the sole factor in trust-building. Following through with promises (D) is crucial but does not address the patient's concerns or doubts directly. Clarifying doubts fosters clear communication and mutual understanding, establishing a foundation of trust.