Nokea
A community health nurse is working with a family in which an elderly woman was neglected by her son and his wife. The elderly woman insists on remaining with the young couple despite the threat of future neglect. Which intervention should be given highest priority?
- A. Identify community resources to decrease the caregivers' stress.
- B. Establish family obligations, client rights, and consequences of abuse and monitor.
- C. Educate the caregivers on the aging process and how to cope with it.
- D. Provide stress management techniques for the caregivers.
Correct Answer: B
Rationale: The correct answer is B because establishing family obligations, client rights, and consequences of abuse is crucial in protecting the elderly woman from neglect. By setting clear boundaries and educating the family on their responsibilities and the consequences of neglect, the nurse can help ensure the woman's safety. This intervention addresses the root cause of the issue and empowers the family to understand and fulfill their duties.
Choice A is incorrect as solely focusing on decreasing caregivers' stress may not address the underlying neglect. Choice C is incorrect as educating caregivers on the aging process does not directly address the neglect issue. Choice D is incorrect as providing stress management techniques does not address the root cause of neglect or establish accountability within the family.
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Which aspect of assessment has priority when a nurse interviews a rape victim?
- A. Coping mechanisms the patient is using
- B. The patient's previous sexual experiences
- C. Adequacy of the patient's interpersonal relationships
- D. Whether the patient has ever had a sexually transmitted disease
Correct Answer: A
Rationale: The correct answer is A: Coping mechanisms the patient is using. This aspect has priority because it helps the nurse assess the immediate emotional and psychological impact of the trauma on the victim. Understanding coping mechanisms can guide the nurse in providing appropriate support and interventions. Choice B is incorrect as past sexual experiences are not as pertinent during the immediate assessment of a rape victim. Choice C is incorrect as assessing interpersonal relationships may not be a priority during the initial interview. Choice D is incorrect as the presence of a sexually transmitted disease is not the primary concern when assessing a rape victim.
The client is describing her trip to town. She tells the nurse, 'I cold town yellow water girl outside below ground.' This speech disturbance is called:
- A. Neologism
- B. Word salad
- C. Flight of ideas
- D. Verbigeration
Correct Answer: B
Rationale: The correct answer is B: Word salad. This speech disturbance is characterized by a jumble of words that lack coherent meaning or connection. In this case, the client's words are disorganized and nonsensical. Neologism (A) is the creation of new words, not a jumble of existing words. Flight of ideas (C) involves rapid shifts in thoughts without a clear connection, not a jumble of words. Verbigeration (D) is the constant repetition of words or phrases, not a jumble of unrelated words.
According to Freud, an individual who experiences problems during the phallic stage of development may have a poorly developed superego. This construct is most relevant to planning care for a client who has the DSM-IV-TR diagnosis of:
- A. Obsessive-compulsive personality disorder
- B. Schizoid personality
- C. Borderline personality disorder
- D. Antisocial personality disorder
Correct Answer: D
Rationale: Step 1: Freud's phallic stage is when the superego develops.
Step 2: Antisocial personality disorder is associated with a poorly developed superego.
Step 3: Individuals with antisocial personality disorder often lack empathy and have a disregard for rules.
Step 4: This behavior aligns with Freud's concept of a weak superego.
Step 5: Therefore, the correct answer is D, Antisocial personality disorder.
Summary: A: Obsessive-compulsive personality disorder is characterized by perfectionism, not related to a weak superego. B: Schizoid personality is marked by social detachment, not directly linked to superego development. C: Borderline personality disorder involves instability in relationships and self-image, not specifically tied to superego development.
A patient who has been physically abused says, 'When I called the police, I just wanted my spouse to stop shoving me around and kicking me. I didn't want anyone to get in trouble. It's easy to get angry with me because I spend too much money.' Which nursing intervention would be most therapeutic for this patient?
- A. You feel your spouse was justified in the abuse because you overspent?'
- B. Tell your spouse that if this happens again, I'll report it to the police.'
- C. Your spouse abuses you when you overspend. So you think it will stop if you stop spending money?'
- D. I can understand that you don't want to press charges, but your spouse needs help controlling anger.'
Correct Answer: A
Rationale: The correct answer is A because it focuses on therapeutic communication by reflecting the patient's feelings and thoughts back to them without judgment. By repeating the patient's words, the nurse shows empathy and understanding, which can help build trust and rapport. Choices B and D may escalate the situation and go against the patient's wishes, potentially causing further harm. Choice C assumes a causal relationship between overspending and abuse, which is not appropriate and may blame the victim. Overall, choice A promotes a non-judgmental and supportive environment, which is crucial in addressing issues of abuse.
The nurse is answering questions from a client and his family regarding a recent diagnosis of Alzheimer's disease. The client asks how effective medication is in treating the disease. What is the nurse's best response?
- A. There is no cure or treatment for Alzheimer's disease.'
- B. Medications have shown little improvement in symptoms.'
- C. Medications for the disease have been found to improve thinking abilities, behavior, and daily functioning in some clients.'
- D. Alternative therapies, such as co-enzyme Q-10 and Ginkgo biloba, are more effective than any of the prescription medications used to treat the symptoms.'
Correct Answer: C
Rationale: The correct answer is C because medications for Alzheimer's disease, such as cholinesterase inhibitors and memantine, have been found to improve thinking abilities, behavior, and daily functioning in some clients. These medications can help manage symptoms and slow down the progression of the disease. Option A is incorrect because while there is no cure for Alzheimer's disease, there are treatments available. Option B is incorrect as medications have shown some efficacy in managing symptoms. Option D is incorrect as there is limited scientific evidence to support the effectiveness of alternative therapies compared to prescription medications for Alzheimer's disease.