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A new nurse asks, “My elderly patient has Lewy body disease. What should I do about assessing for pain?” Select the best response from the nurse manager.
- A. Ask the patient’s family if they think the patient is experiencing pain.
- B. Use a visual analog scale to help the patient determine the presence and severity of pain.
- C. There are special scales for assessing patients with dementia. Let’s review how to use them.
- D. The perception of pain is diminished by this type of dementia. Focus your assessment on the patient’s mental status.
Correct Answer: C
Rationale: The correct answer is C because Lewy body disease can affect a patient's ability to communicate pain, making specialized pain assessment tools crucial. Special scales designed for patients with dementia can help in accurately assessing pain levels. These tools consider non-verbal cues and behavioral changes that may indicate pain. Asking the patient's family (A) may not always provide an accurate assessment of pain perception. Using a visual analog scale (B) may be challenging for a patient with cognitive impairment. Focusing solely on mental status (D) may overlook important indicators of pain in patients with Lewy body disease.
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The nurse is collecting the paintings from the patients after the art session is over. After art therapy, a patient hands the nurse a paper that consists of several black scribbles. Which statement demonstrates the nurse understands the goals and objectives of the therapy?
- A. “I see that you don’t take this very seriously.”
- B. “Can you tell me what happened to prompt such work?”
- C. “Do you want to complete your painting?”
- D. “That’s interesting. It looks like you’re frustrated.”
Correct Answer: B
Rationale: The correct answer is B because it shows empathy and encouragement for the patient to express their feelings. By asking what prompted the artwork, the nurse demonstrates understanding and willingness to explore the patient's emotions. Choice A is judgmental and dismissive, not fostering a therapeutic relationship. Choice C is directive and may pressure the patient. Choice D makes an assumption about the patient's emotions without allowing them to share their perspective.
A nurse is working with a group of older adults attending a seminar on the physical and emotional effects of aging. Which patient statements are good predictors of positive well-being and perceived mortality? (Select all that apply.)
“Not having to deal with the stress of any major chronic illnesses.”
- A. “Being satisfied with growing older.”
- B. “Feeling younger than my birthdays say I should.”
- C. “Retirement gives me time to do the things I’ve put off doing.”
- D. “At least I don’t have to worry about having enough money to retire.
Correct Answer: A, C
Rationale: The correct answers are A and C. Statement A indicates a positive attitude towards aging, which is a good predictor of positive well-being. Feeling satisfied with growing older can lead to better emotional health and higher perceived mortality. Statement C suggests that retirement provides opportunities for personal fulfillment, which can contribute to positive well-being. Statements B and D do not directly address attitudes towards aging or well-being, making them less reliable predictors.
A nurse administers pure oxygen to a client during and after electroconvulsive therapy. What is the nurse’s rationale for this procedure?
- A. To prevent increased intracranial pressure resulting from anoxia
- B. To prevent anoxia due to medication-induced paralysis of respiratory muscles
- C. To prevent hypotension, bradycardia, and bradypnea due to electrical stimulation
- D. To prevent blocked airway resulting from seizure activity
Correct Answer: B
Rationale: The correct answer is B: To prevent anoxia due to medication-induced paralysis of respiratory muscles. During electroconvulsive therapy, muscle relaxants are often used to prevent injury during the seizure. These medications can lead to paralysis of respiratory muscles, causing potential anoxia if oxygen is not administered. Providing pure oxygen ensures adequate oxygenation despite muscle paralysis.
Incorrect Choices:
A: Preventing increased intracranial pressure is not the primary rationale for administering oxygen during ECT.
C: Hypotension, bradycardia, and bradypnea are potential side effects of ECT itself, but oxygen administration is not primarily to prevent these.
D: Oxygen is not administered to prevent a blocked airway but rather to ensure adequate oxygenation during muscle paralysis.
Which developmental level would be characterized by a child being able to focus, coordinate, and imagine a series of events?
.
- A. Preoperational
- B. Concrete operational
- C. Formal operational
- D. Postoperational
Correct Answer: B
Rationale: The correct answer is B: Concrete operational. At this developmental level, children typically exhibit the ability to focus, coordinate, and imagine a series of events. This stage, according to Piaget's theory, usually occurs around ages 7 to 11. Children at this stage can perform logical operations, understand conservation, and think more systematically.
A: Preoperational - Children at this stage (ages 2-7) lack the ability to perform logical operations and struggle with understanding conservation and cause-and-effect relationships.
C: Formal operational - This stage (typically starting around age 11) involves abstract thinking, hypothetical reasoning, and problem-solving beyond the concrete level.
D: Postoperational - This term is not a recognized developmental stage in Piaget's theory.
By the end of the orientation phase, which outcome can be identified for a newly admittedpatient? The patient will demonstrate:
- A. Positive transference with a staff member
- B. Ability to ask for help in meeting needs
- C. Commitment to long-term therapy
- D. Ability to manage symptoms independently
Correct Answer: A
Rationale: The correct answer is A because positive transference with a staff member in the orientation phase indicates a developing therapeutic relationship, which is crucial for effective treatment. This outcome shows the patient is beginning to trust and feel safe with a staff member, enhancing their engagement in therapy.
Choice B is incorrect because the ability to ask for help in meeting needs may not be fully developed by the end of the orientation phase. Choice C is incorrect as commitment to long-term therapy is usually not established this early in the process. Choice D is incorrect because the ability to manage symptoms independently typically requires more time and therapy progress.