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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 common nursing diagnosis for a patient with antisocial personality disorder is:
- A. chronic low self-esteem, related to poor self-image and excessive fear of failure
- B. disturbed thought processes, related to sensory-perceptual alterations
- C. impaired social interaction, related to manipulative behaviors
- D. social isolation, related to anxiety in social situations
Correct Answer: C
Rationale: Impaired social interaction due to manipulation reflects the interpersonal challenges of antisocial personality disorder.
An 11-year-old boy stays home from school to care for his siblings while his mother works, because the family cannot afford a babysitter. During the community mental health nurse's visit, he reveals that he thinks his father does not like him because he calls him 'stupid' all the time. He states he is too dumb to learn much and has no friends at school because he does not deserve them. Which nursing diagnosis should be the priority for the child?
- A. Helplessness
- B. Knowledge deficit
- C. Ineffective coping
- D. Chronic low self-esteem
Correct Answer: D
Rationale: The correct answer is D: Chronic low self-esteem. This diagnosis is appropriate because the child displays a negative self-concept, feeling unworthy, lacking confidence, and believing he is "stupid" and undeserving of friends. This impacts his self-worth and psychological well-being. Chronic low self-esteem is the priority to address as it affects various aspects of his life.
Choice A: Helplessness may seem relevant due to the family situation, but the child's core issue is more about self-worth than feeling helpless in his situation.
Choice B: Knowledge deficit is not the priority as the child's issue lies more in his emotional well-being rather than lack of information.
Choice C: Ineffective coping might be a concern, but the root of his struggles is his self-esteem, making chronic low self-esteem the primary focus.
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 takes responsibility for events that are not entirely their fault. In this scenario, the patient is attributing the laughter of people in the check-out line to being about them and their weight gain, when in reality, the laughter may have had nothing to do with them. This distortion can contribute to feelings of guilt, shame, and self-blame.
A: Magnification involves exaggerating the importance or meaning of an event, which is not evident in the scenario.
C: Overgeneralization involves making broad negative conclusions based on a single event, which is not demonstrated here.
D: Dichotomous thinking is the tendency to view situations in black and white terms, with no middle ground, which is not present in the patient's statement.
The Freudian explanation of anxiety disorders emphasizes
- A. the avoidance paradox
- B. learned habits of self-defeating behavior
- C. forbidden impulses that threaten a loss of control
- D. the development of a faulty or inaccurate self-image and distorted self-perceptions
Correct Answer: C
Rationale: Freud viewed anxiety as stemming from repressed impulses threatening to surface, disrupting control.
The average time that a person with Alzheimer's disease lives after diagnosis is:
- A. 2 years
- B. 8 years
- C. 10 years
- D. 20 years
Correct Answer: B
Rationale: The correct answer is B: 8 years. Alzheimer's disease typically progresses slowly, with individuals living an average of 8 years after diagnosis. This is due to the degenerative nature of the disease, leading to gradual decline in cognitive function. Choice A (2 years) is too short for Alzheimer's progression. Choice C (10 years) is close but slightly overestimates the average. Choice D (20 years) is too long, as Alzheimer's typically does not allow for such a long survival time post-diagnosis. Therefore, B is the most accurate option based on the typical progression and outcomes of Alzheimer's disease.