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A health care provider writes these new prescriptions for a resident in a skilled nursing facility: 2G sodium diet, Restraint as needed, Limit fluids to 1800~mL daily, Continue antihypertensive medication, Milk of magnesia 30~mL PO once if no bowel movement for 3 days. The nurse should:
- A. question the fluid restriction
- B. question the order for restraint
- C. transcribe the prescriptions as written
- D. assess the residents bowel elimination
Correct Answer: B
Rationale: Restraints may be imposed only on a written order of the health care provider that specifies the duration during which the restraints can be used. The Joint Commission guidelines and Omnibus Budget Reconciliation Act regulations also mandate a number of other conditions that must be considered and documented before restraints are used. The other prescriptions are appropriate.
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The nurse is assisting a victim of spousal abuse to create a plan for escape if it becomes necessary. What components should the plan include? Select all that apply.
- A. A code word to signal children that it is time to leave.
- B. Phone numbers for the nearest shelter and crisis hotline.
- C. Telling the spouse that she has a plan and will leave.
- D. Collecting birth certificates and other essential documents.
Correct Answer: A
Rationale: The correct answer is A: A code word to signal children that it is time to leave. This is crucial for ensuring the safety of the victim and their children without alerting the abuser. Other choices like B, providing phone numbers for shelters, are important but may not always be feasible in an emergency. Choice C, informing the spouse about the plan, can escalate the situation. Choice D, collecting essential documents, is important but may not always be the immediate priority in a dangerous situation. Having a code word ensures a discreet and quick escape if needed.
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 depressed patient tells the nurse, "The bad things that happen are always my fault." How should the nurse respond to assist the patient to reframe this overgeneralization?
- A. I really doubt that one person can be blamed for all the bad things that happen.
- B. You are being exceptionally hard on yourself when you imply you are a jinx.
- C. What about the good things that happen; are any of those ever your fault?
- D. Let's look at one bad thing that happened to see if another explanation exists.
Correct Answer: D
Rationale: The correct answer is D because it encourages the patient to challenge the overgeneralization by exploring alternative explanations for a specific event. By examining one bad thing in detail, the patient can see that not everything is their fault, promoting a more balanced perspective.
A is incorrect because it simply doubts the patient's statement without providing a constructive way to reframe it. B is incorrect as it introduces the idea of being a jinx, which may further reinforce the patient's negative self-perception. C is incorrect as it diverts the focus to good things, which does not address the patient's negative beliefs about themselves.
Which of these nursing communications best reflects the nurse's use of an empowerment model with an individual who has been abused?
- A. Let me share with you my knowledge of what happens psychologically to individuals who have been abused.'
- B. I know you feel that your partner will change, but the current research does not validate your thinking.'
- C. It's up to you to end the violence. You are the only one who can set limits on how your partner is allowed to treat you.'
- D. Let's consider what you believe your options are in terms of your relationship with your partner in light of the behavior toward you.'
Correct Answer: D
Rationale: The correct answer, D, reflects the nurse's use of an empowerment model because it focuses on exploring the individual's beliefs and options, empowering them to make informed decisions. The nurse is not imposing their own knowledge or opinions but instead facilitating the individual's self-reflection and decision-making process. This approach respects the individual's autonomy and promotes empowerment by helping them identify and evaluate their own choices.
Choice A focuses on the nurse sharing knowledge, which may come across as patronizing and disempowering. Choice B dismisses the individual's feelings and relies on research rather than empowering the individual to make their own decisions. Choice C places the responsibility solely on the individual to end the violence, which may feel overwhelming and lacking in support or guidance.
A 25-year-old individual was brought by ambulance to the emergency room. The patient's sensorium alternates between clouded and clear, and the patient becomes agitated both physically and verbally when approached. The patient's cognitive impairment is most consistent with:
- A. Delirium
- B. Dementia
- C. Sundown syndrome
- D. Early-onset Alzheimer disease
Correct Answer: A
Rationale: The correct answer is A: Delirium. Delirium is characterized by acute onset, fluctuating course, altered level of consciousness, and cognitive impairment. In this case, the patient's alternating sensorium and agitation suggest an acute confusional state, which is typical of delirium. Delirium is often caused by underlying medical conditions, medications, or substance abuse.
Summary of other choices:
B: Dementia is a chronic, progressive cognitive decline that does not typically present with acute onset and fluctuating symptoms like delirium.
C: Sundown syndrome refers to worsening of symptoms in the evening and is often seen in patients with dementia, not in this acute and fluctuating presentation.
D: Early-onset Alzheimer's disease is a form of dementia that typically has a more insidious onset and does not present with acute fluctuations in cognition like delirium.