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A client with moderate to severe dementia does not remember her son's name. The son repeatedly questions the mother when he visits the dementia facility, asking, 'Do you know my name?' The mother invariably becomes agitated. The nurse can most effectively intervene by explaining to the son:
- A. Your mother is angry with you and is punishing you by 'forgetting' who you are. Be patient and she'll get over it.'
- B. I know it is difficult for you, but your mother's dementia is severe and she cannot retain information even for short periods of time. She senses your distress and becomes agitated.'
- C. Although it's a strain for you, you will need to reorient your mother as often as you can, during the time you are with her. With repetition, she may be able to understand and recall what you are saying.'
- D. Because you become so distressed, it might be better if you come to see your mother only once a week and stay for only a short time.'
Correct Answer: B
Rationale: Rationale:
1. Correct Answer (B): Explains the son's mother's inability to retain information due to severe dementia, causing agitation. Validates son's feelings and provides insight into the mother's behavior.
2. Incorrect Answer (A): Falsely suggests the mother is punishing the son by forgetting, potentially causing misunderstanding and blame.
3. Incorrect Answer (C): Implies the son should solely focus on reorienting the mother, overlooking the emotional impact and distress caused by repetitive questioning.
4. Incorrect Answer (D): Suggests limiting visits based on the son's distress, rather than addressing the root cause of agitation caused by the mother's dementia.
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A patient who has been taking fluoxetine (Prozac) 60 mg daily for the past 6 months tells the nurse at the medication follow-up clinic that he is considering stopping the Prozac. He states his mood is fine, and now that he is living normally, his wife is concerned that he has no sex drive. Which response would be best?
- A. Without the medicine the depression will likely return; you and your wife will need to adjust to the sexual side effects.
- B. If we switch your medication time to the morning, the sexual side effects will be worn off in time for evening sexual activity.
- C. The problem is not likely due to the medicine. Often the depression itself, even after it improves, continues to dampen sex drive.
- D. Without an antidepressant, the depression is more likely to reoccur, but there are other medications that do not interfere so much with sex.
Correct Answer: D
Rationale: Step-by-step rationale for why answer D is correct:
1. Correctly acknowledges the patient's concern about sexual side effects.
2. Highlights the importance of managing depression to prevent recurrence.
3. Offers a solution by mentioning alternative medications with less impact on sex drive.
4. Empowers the patient by providing information and options for treatment.
5. Addresses both the patient's current situation and long-term mental health needs.
Summary of why other choices are incorrect:
A: Overlooks the patient's valid concern about sexual side effects and lacks a proactive solution.
B: Focuses on timing of medication without addressing the underlying issue of sexual side effects.
C: Dismisses the patient's concern and fails to provide a solution or alternative options.
Which intervention would be the best initial approach for a nurse to take when a young adult patient is verbally abusive?
- A. Ask the patient to define 'verbally abusive language.'
- B. Provide the patient with examples of assertive communication.
- C. Identify the patient's verbal abuse in order to set standards for future dialogue.
- D. Remove privileges from the patient until communications show less aggression.
Correct Answer: C
Rationale: The correct initial approach is to identify the patient's verbal abuse to set standards for future dialogue. This approach addresses the behavior directly, establishes boundaries, and communicates expectations for respectful communication. Asking the patient to define 'verbally abusive language' (choice A) may not effectively address the current behavior. Providing examples of assertive communication (choice B) may not directly address the abusive behavior. Removing privileges (choice D) may escalate the situation and is not a constructive communication strategy. By identifying the patient's verbal abuse, the nurse can address the behavior effectively and work towards a respectful and therapeutic relationship.
Which nursing diagnosis would be appropriate for a patient with Alzheimer disease?
- A. Disorientation related to hyperthermia
- B. Anxiety (moderate) related to dementia
- C. Disturbed sensory perception (visual) related to alcohol abuse
- D. Disturbed thought processes related to irreversible brain disorder
Correct Answer: D
Rationale: The correct answer is D: Disturbed thought processes related to irreversible brain disorder. This nursing diagnosis is appropriate for a patient with Alzheimer's disease because Alzheimer's is characterized by cognitive decline and disturbances in thought processes due to irreversible brain changes. Disorientation related to hyperthermia (A) is not directly associated with Alzheimer's. Anxiety related to dementia (B) is a symptom of Alzheimer's, not a nursing diagnosis. Disturbed sensory perception related to alcohol abuse (C) is not relevant to a patient with Alzheimer's disease. It is crucial to focus on the specific symptoms and characteristics of Alzheimer's disease when selecting the appropriate nursing diagnosis.
A nurse interviews a patient abducted and raped at gunpoint by an unknown assailant. The patient says, "I can't talk about it. Nothing happened. I have to forget."Â What is the patient's present coping strategy?
- A. Somatization
- B. Repression
- C. Projection
- D. Denial
Correct Answer: D
Rationale: The correct answer is D: Denial. The patient's statement of "I can't talk about it. Nothing happened. I have to forget" indicates a denial coping strategy. Denial is a defense mechanism where individuals refuse to acknowledge a stressful situation or event. In this case, the patient is attempting to block out the traumatic experience of being abducted and raped by denying its existence. This coping mechanism helps the individual temporarily avoid the emotional distress associated with the event.
A: Somatization involves expressing emotional distress through physical symptoms, which is not evident in the patient's statement.
B: Repression is the unconscious blocking of unpleasant memories, whereas the patient is consciously trying to forget the event.
C: Projection involves attributing one's own thoughts or feelings to others, which is not demonstrated in the patient's statement.
In summary, the patient's use of denial as a coping strategy is evident in their attempt to minimize the traumatic experience by refusing to acknowledge it.
A student transfers from a hometown college to a university 200 miles away after breaking up with her boyfriend of 2 years. She was slow to make friends at the university. The history shows a close relationship with her mother and sister. She began eating large quantities when she felt sad, and then she induced vomiting. When the student's schoolwork declined, she sought help. During the initial interview, what priority issue should the nurse address?
- A. Losses.
- B. Sleep patterns.
- C. School activities.
- D. None of the above.
Correct Answer: A
Rationale: The correct answer is A: Losses. The priority issue the nurse should address is the student's losses, such as the breakup with her boyfriend and the difficulty in making friends at the new university. This is important because these losses may be contributing to her emotional distress and maladaptive coping mechanisms like binge-eating and induced vomiting. The nurse needs to explore these losses to understand the root cause of the student's behavior and provide appropriate support.
Choice B: Sleep patterns, and Choice C: School activities are not the priority issues in this scenario. While sleep patterns and school activities are important aspects of the student's life, the primary concern here is addressing the emotional impact of the losses she has experienced.
Choice D: None of the above is incorrect because losses are indeed the priority issue that needs to be addressed in this situation. Ignoring the emotional impact of the student's losses could hinder the effectiveness of any interventions or support provided.