Nokea
A client with dementia was admitted to a dementia unit after she began persistently wandering away from home. The nursing staff should plan to:
- A. Provide unlimited freedom because the client has no place to go in the new neighborhood
- B. Provide one-to-one supervision when the client is ambulatory
- C. Place the client in a geriatric chair with a tray across the lap
- D. Provide the client with an electronic alarm that sounds when the client nears the exit door
Correct Answer: D
Rationale: The correct answer is D because providing the client with an electronic alarm that sounds when she nears the exit door is the best option to ensure her safety. This approach allows for monitoring without restricting her movement excessively. Choice A is incorrect as unlimited freedom poses risks. Choice B is not practical or feasible long-term. Choice C is not person-centered and may lead to discomfort and agitation. The electronic alarm in choice D is the most effective and least intrusive method to prevent wandering while respecting the client's autonomy.
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A victim of a sexual assault sits in the emergency department rocking back and forth and repeatedly saying, "I can't believe I've been raped."Â This behavior is characteristic of:
- A. The acute phase reaction.
- B. The angry stage of rape-trauma syndrome.
- C. A delayed reaction to rape-trauma syndrome.
- D. The long-term phase of rape-trauma syndrome.
Correct Answer: A
Rationale: The correct answer is A: The acute phase reaction. This behavior is characteristic of the immediate emotional response following a traumatic event like sexual assault. The victim may exhibit shock, disbelief, and emotional distress. In this scenario, the victim's reaction of disbelief and repetitive statements align with the acute phase reaction. The other options are incorrect because the angry stage (B) and delayed reaction (C) occur later in the trauma response process, while the long-term phase (D) reflects a more prolonged period of adjustment and coping.
A nurse assesses four patients between the ages of 70 and 80. Which patient has the highest risk for alcohol abuse? The patient who:
- A. consumes 1 glass of wine nightly with dinner
- B. began drinking alcohol daily after retirement and says, 'A few drinks keep my mind off my arthritis.'
- C. drank socially throughout adult life and continues this pattern, saying 'Ive earned the right to do as I please.'
- D. abused alcohol between the ages of 25 and 40 but now abstains and occasionally attends Alcoholics Anonymous (AA)
Correct Answer: B
Rationale: Alcohol abuse and dependence can develop at any age, and the geriatric population is particularly at risk. Losses, such as retirement, widowhood, and loneliness, are often related. The distracters describe patients with a lower risk for alcohol abuse.
A patient is admitted with a tentative diagnosis of delirium. The patient repeatedly mistakes one of the nursing staff for a family member. The nurse documents that this patient is experiencing a disturbance in which area of functioning?
- A. Consciousness
- B. Attention
- C. Perception
- D. Cognition
Correct Answer: C
Rationale: The correct answer is C: Perception. In this scenario, the patient's repeated mistake of identifying a nursing staff as a family member indicates a disturbance in perception, specifically in the recognition and interpretation of sensory information. This confusion is not related to consciousness (A), as the patient is awake and aware. It is also not solely an issue of attention (B), as attention involves the ability to focus on specific stimuli rather than the interpretation of those stimuli. While cognition (D) encompasses various mental processes, such as memory and problem-solving, the primary issue in this case is the misinterpretation of sensory input, aligning with the disturbance in perception.
Which statement by the nurse indicates a good understanding of postpartum blues?
- A. You need to get involved with taking care of this baby.
- B. You are lucky to have a healthy baby. The patient in the next room would give anything to be in your place.
- C. You look tired. Why dont you rest for a bit and I will come back later to start some teaching.
- D. I will call the social worker to check into alternate caregiving for the new baby.
Correct Answer: C
Rationale: This response (C) indicates understanding that postpartum blues is transient and that time and rest are major healers. The other responses (A, B, D) are judgmental or inappropriate.
A patient has recently been under significant stress and worked long hours. At home, the patient watches television and eats until going to bed. The patient is too tired to exercise and has gained 25 pounds in 1 month. A desired outcome for the patient is to recognize anxiety that precedes binge eating and reduce it. Which intervention addresses the outcome
- A. Teach stress-reduction techniques such as relaxation and imagery.
- B. Encourage the patient to design and implement an exercise program.
- C. Explore ways in which the patient may feel more in control of the environment.
- D. Encourage the patient to attend a support group such as Overeaters Anonymous.
Correct Answer: A
Rationale: The correct answer is A: Teach stress-reduction techniques such as relaxation and imagery. This intervention directly addresses the desired outcome of recognizing anxiety that precedes binge eating and reducing it. By teaching stress-reduction techniques, the patient can learn to identify triggers, manage stress, and reduce the likelihood of turning to binge eating. Relaxation and imagery can help the patient relax and focus on positive thoughts, thus breaking the cycle of stress-induced binge eating.
Option B is incorrect because while exercise is beneficial for overall health, it does not directly address recognizing and reducing anxiety that leads to binge eating. Option C is incorrect as feeling more in control of the environment may help, but it does not specifically target anxiety reduction related to binge eating. Option D is incorrect as attending a support group may be helpful for some aspects of recovery, but it does not focus on recognizing and reducing anxiety specifically.