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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 patients 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. Lets review how to use them.'
- D. The perception of pain is diminished by this type of dementia. Focus your assessment on the patients mental status.'
Correct Answer: C
Rationale: Lewy body disease is a form of dementia. There are special scales to assess the presence and severity of pain in patients with dementia. The Pain Assessment in Advanced Dementia Scale evaluates breathing, negative vocalizations, body language, and consolability. A patient with dementia would be unable to use a visual analog scale. The family may be able to help the nurse gain perspective about the pain, but this strategy alone is inadequate. The other distracters are myths.
You may also like to solve these questions
Male erectile disorder is always the result of psychological factors
- A. TRUE
- B. FALSE
Correct Answer: B
Rationale: Erectile disorder can stem from both psychological (e.g., anxiety) and physical (e.g., vascular) causes.
According to statistical research data, which of these children currently being followed by the pediatric nurse practitioner is at the greatest risk for fatal abuse?
- A. A child who is 2 years old and has cerebral palsy
- B. A child who is 5 years old and has measles
- C. A child who is 8 years old and has appendicitis
- D. A child who is 11 years old and has a fractured humerus
Correct Answer: A
Rationale: The correct answer is A because young children with disabilities, like cerebral palsy, are at the highest risk for fatal abuse based on statistical research. These children may be more vulnerable due to their dependency on caregivers and communication challenges. Choice B is incorrect as measles, although serious, is not associated with fatal abuse. Choice C is incorrect as appendicitis is a medical condition and not a risk factor for abuse. Choice D is incorrect as a fractured humerus, while concerning, does not indicate a higher risk for fatal abuse compared to a child with cerebral palsy.
A catatonic patient admitted in a stuporous condition begins to demonstrate increased motor activity. During his assessment, the psychiatrist raises the patient's arm above his head and releases it. The patient maintains the position his arm was placed in, immobile in that position for 15 minutes, moving only when the nurse gently lowers his arm. What symptom is demonstrated by this assessment technique?
- A. Echopraxia
- B. Waxy flexibility
- C. Depersonalization
- D. Thought withdrawal
Correct Answer: B
Rationale: The correct answer is B: Waxy flexibility. This symptom is demonstrated by the patient's ability to maintain the position his arm was placed in, immobile, for an extended period of time. This is characteristic of catatonia, where individuals exhibit increased motor activity and abnormal posturing. Waxy flexibility refers to the tendency of catatonic patients to maintain positions that they are placed in by others, almost as if their limbs are made of wax and can be molded into different positions.
Explanation for other choices:
A: Echopraxia involves mimicking the movements of others, which is not demonstrated in this scenario.
C: Depersonalization refers to feeling detached from oneself, which is not evident in the patient's behavior during the assessment.
D: Thought withdrawal is a symptom of schizophrenia where thoughts are believed to be removed from one's mind by an external force, which is not relevant to the patient's motor behavior in this case.
Which of the following is the most important initial intervention for a patient with bulimia nervosa?
- A. Provide a structured mealtime environment with supervision.
- B. Encourage the patient to participate in support groups immediately.
- C. Administer antianxiety medications as prescribed.
- D. Assess the patient's family dynamics and home environment.
Correct Answer: A
Rationale: The correct answer is A: Provide a structured mealtime environment with supervision. This is the most important initial intervention for a patient with bulimia nervosa because it addresses the immediate health concern of disordered eating behavior. By providing a structured mealtime environment with supervision, the patient can establish regular eating patterns, learn healthier eating habits, and reduce the risk of purging behaviors. This intervention also helps in restoring proper nutrition and addressing any underlying issues related to food and eating.
Choice B is incorrect because support groups may be beneficial but are not the most critical initial intervention. Choice C is incorrect as antianxiety medications do not directly address the disordered eating behavior. Choice D is also incorrect as assessing family dynamics and home environment is important but not as crucial as addressing the immediate eating disorder symptoms.
If you met an individual who appeared to be very charming at first, but later you discovered that he or she manipulated people, caused others hurt without a second thought, and could not be depended upon, you might suspect him of being
- A. dependent
- B. narcissistic
- C. paranoid
- D. antisocial
Correct Answer: D
Rationale: Antisocial personality disorder features charm, manipulation, and lack of remorse, fitting this description perfectly.