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A community health nurse visits an elderly person whose spouse died 6 months ago. Two vodka bottles are in the trash. When the nurse asks about alcohol use, this person says, 'I get lonely and drink a little to help me forget.' Select the nurses most therapeutic intervention.
- A. Assess whether this patient is drinking and driving
- B. Advise the person not to drink alone because the risks for injury increase
- C. Teach the person about risks for alcoholism and suggest other coping strategies
- D. Arrange for the person to attend an Alcoholics Anonymous meeting for older adults
Correct Answer: D
Rationale: This person needs help with alcohol abuse as well as social involvement. An AA meeting for older adults will provide an opportunity for peer bonding as well as strategies for coping with stress without abusing alcohol. The distracters will not be therapeutic in this instance.
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Which beliefs by a nurse facilitate provision of safe, effective care for older adult patients? Select one tha does not apply.
- A. Sexual interest declines with aging.
- B. Older adults are able to learn new tasks.
- C. Aging results in a decline in restorative sleep.
- D. Older adults are prone to become crime victims.
Correct Answer: A
Rationale: Older adults can learn new tasks (B), experience a decline in restorative sleep (C), and are prone to crime (D), aiding effective care. Sexual interest doesn't universally decline (A), and isolation isn't typical (E); these are myths.
A person who was raped comes to the hospital for treatment. The person abruptly decides to decline treatment and leave the facility. Before this person leaves, the nurse should:
- A. Say, "You may not leave until you're given prophylactic treatment for sexually transmitted diseases."Â
- B. Provide written information about physical and emotional reactions the person may experience.
- C. Explain the need and importance of HIV and pregnancy tests.
- D. Give verbal information about legal resources.
Correct Answer: B
Rationale: The correct answer is B because providing written information about physical and emotional reactions respects the individual's autonomy and empowers them to make informed decisions. It also ensures they have resources to understand and cope with potential consequences. Choice A violates the individual's right to refuse treatment. Choice C focuses on specific tests without addressing the person's immediate concerns. Choice D, while important, is not as immediate or relevant as providing information on potential reactions.
A patient receiving risperidone (Risperdal) reports severe muscle stiffness midmorning. During lunch he has difficulty swallowing food and speaking, and when vital signs are taken 30 minutes later, he is noted to be stuporous and diaphoretic, with a temperature of 38.8° C, pulse of 110 beats/min, and blood pressure of 150/90 mm Hg. The nurse should suspect ______ and should ______.
- A. neuroleptic malignant syndrome"¦place him in a cooling blanket and transfer to ICU
- B. anticholinergic toxicity"¦check vital signs and prepare to use a cooling blanket stat
- C. relapse of his psychosis"¦administer PRN antipsychotic drugs and notify his physician
- D. agranulocytosis"¦hold his antipsychotic and draw blood for a complete blood count
Correct Answer: A
Rationale: The correct answer is A: neuroleptic malignant syndrome (NMS). The patient's symptoms align with NMS, a rare but serious side effect of antipsychotic medications like risperidone. The severe muscle stiffness, difficulty swallowing, altered mental status, diaphoresis, and elevated temperature, pulse, and blood pressure are all indicative of NMS. The nurse should suspect NMS and take immediate action by placing the patient in a cooling blanket to lower the temperature and transfer him to the ICU for close monitoring and further management.
Choice B is incorrect because anticholinergic toxicity typically presents with different symptoms such as dry mouth, dilated pupils, and confusion. Choice C is incorrect as there are no signs of a psychotic relapse, and administering more antipsychotic medication could worsen the NMS. Choice D is incorrect as agranulocytosis presents with symptoms like fever and sore throat, not the combination of symptoms seen in this case.
What is the primary goal for a nurse treating a patient with anorexia nervosa?
- A. To help the patient achieve optimal body weight quickly.
- B. To restore the patient's nutritional balance and weight.
- C. To involve the patient in daily exercise routines to improve physical health.
- D. To encourage the patient to undergo intensive psychotherapy.
Correct Answer: B
Rationale: The primary goal for a nurse treating a patient with anorexia nervosa is to restore the patient's nutritional balance and weight. This is because individuals with anorexia nervosa often have severe malnutrition and weight loss, which can lead to serious health complications. By focusing on restoring nutritional balance and weight, the nurse can help improve the patient's physical health and overall well-being. Encouraging the patient to achieve optimal body weight quickly (choice A) may not be realistic or safe, as rapid weight gain can have negative consequences. Involving the patient in daily exercise routines (choice C) may exacerbate the patient's compulsive behaviors around food and exercise. Encouraging the patient to undergo intensive psychotherapy (choice D) is important, but it is not the primary goal in the initial treatment of anorexia nervosa.
A patient who is admitted to the psychiatric unit with a diagnosis of obsessive-compulsive disorder spends a significant amount of time during the day and night washing their hands. On the third hospital day, the patient reports feeling better and more comfortable with the staff and other patients. The psychiatric-mental health nurse knows that the most appropriate nursing intervention is to:
- A. acknowledge the ritualistic behavior each time and point out that it is inappropriate
- B. allow the patient to carry out the ritualistic behavior, since it is helping them
- C. collaborate with the patient to reduce the amount of time they engage in ritualistic behavior
- D. ignore the ritualistic behaviors, and the behaviors will be eliminated due to lack of reinforcement
Correct Answer: C
Rationale: Collaborating to reduce rituals builds on the patient's progress, promoting control without enabling the behavior.