Nokea
A new nurse asks the experienced nurse who is caring for a battered woman client, 'Why did you ask about culture when it was obvious you needed to focus on the battering?' The experienced nurse should respond:
- A. It's just a habit I got into a while ago.'
- B. It helps me focus on whether to do a complete physical assessment.'
- C. Culture is a determinant of how women interpret and respond to violence.'
- D. If I know more about her I can refer her to a shelter that caters to her ethnic group.'
Correct Answer: C
Rationale: Rationale:
- Choice C is correct because culture influences how individuals perceive and respond to violence, impacting their help-seeking behaviors and coping mechanisms.
- Understanding the client's cultural background is crucial for providing appropriate care and support.
- Choices A, B, and D are incorrect as they do not address the importance of considering culture in understanding and addressing domestic violence in this context.
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A family has noted the following behaviors in one of their elderly parents: periodic indecisiveness, forgetfulness, mild transient confusion, occasional misperception, distractibility, and occasional unclear thinking. Where on the continuum of cognitive responses would this patient be?
- A. At point 1
- B. At point 2
- C. At point 3
- D. There is insufficient information to make a determination.
Correct Answer: B
Rationale: The correct answer is B: At point 2. This patient's symptoms indicate mild cognitive impairment, which falls between normal age-related decline (point 1) and dementia (point 3). Mild cognitive impairment involves noticeable cognitive changes but does not significantly interfere with daily functioning. Point 1 is too mild for the symptoms described, and point 3 is too severe as the patient's symptoms are not indicative of full-blown dementia. Therefore, the patient is best placed at point 2 on the continuum of cognitive responses.
During a manic episode, a patient is hyperactive, restless, and disorganized. The patient goes to the dining room and begins to throw food and dishes. Verbal intervention is ineffective. The patient's behavior poses a substantial risk of harm to others. Staff escorts the patient to the patient's room to dine alone. What is the rationale for this action?
- A. Prevent other patients from observing the behavior.
- B. Reduce environmental stimuli that negatively affect the patient.
- C. Protect the patient's biological integrity until medication takes effect.
- D. Reinforce limit setting
Correct Answer: B
Rationale: The correct answer is B: Reduce environmental stimuli that negatively affect the patient. This action helps reduce stimulation that may be exacerbating the manic episode, promoting a calmer environment for the patient. Removing the patient from the dining room minimizes triggers for further disruptive behavior. This approach prioritizes the patient's well-being by managing the environmental factors contributing to the escalation of symptoms.
A: Preventing other patients from observing the behavior does not directly address the patient's needs during the manic episode and does not actively help in managing the situation.
C: Protecting the patient's biological integrity until medication takes effect may be important, but in this scenario, the immediate focus is on addressing the environmental factors contributing to the behavior.
D: Reinforcing limit setting is important in managing behavior, but in this specific situation, reducing environmental stimuli is a more immediate and effective intervention.
A patient moving from chair to chair in the day room and pacing in the hallway repeatedly, rapidly, and for extended periods is likely demonstrating ______, and the nurse should ______.
- A. a dystonic reaction"¦administer PRN IM benztropine (Cogentin)
- B. anxiety"¦ teach and guide the patient to use relaxation exercises
- C. akathisia"¦administer PRN diphenhydramine (Benadryl) PO
- D. tardive dyskinesia"¦recommend a change in medication
Correct Answer: C
Rationale: The correct answer is C: akathisia"¦administer PRN diphenhydramine (Benadryl) PO. Akathisia is characterized by restlessness and an inability to sit still. Administering diphenhydramine can help alleviate these symptoms. A is incorrect because dystonic reactions present with muscle spasms and abnormal postures, not restlessness. B is incorrect as anxiety does not typically manifest as physical restlessness. D is incorrect as tardive dyskinesia involves involuntary movements of the face and body, not restlessness.
When a nurse overhears the spouse of a patient threaten to 'smack you good if you don't shut up' while sitting in the unit's dayroom, which action reflects the most immediate, therapeutic nursing intervention?
- A. Notify hospital security immediately that the situation exists!
- B. Tell the spouse, 'Your presence is no longer permitted on the unit.'
- C. Ask the patient if the spouse has ever engaged in physically abusive behavior.
- D. Tell the spouse, 'The police will be called unless you leave immediately.'
Correct Answer: A
Rationale: The correct answer is A: Notify hospital security immediately that the situation exists. This is the most immediate, therapeutic nursing intervention because the safety of the nurse, patient, and others in the unit is the top priority. By involving hospital security, the nurse can ensure a swift and appropriate response to the threatening behavior. This action helps to de-escalate the situation and protect everyone involved.
The other choices are incorrect because:
B: Asking the spouse to leave the unit could escalate the situation further and put the nurse at risk.
C: Asking the patient about the spouse's behavior may not be immediate enough to address the threat.
D: Threatening to call the police could escalate the situation and may not be the best approach to ensure safety for all parties involved.
The intervention of highest priority for a client with stage 3 Alzheimer's disease is to:
- A. Provide a stimulating environment
- B. Maintain hydration and nutrition
- C. Set limits on behavioral disinhibition
- D. Promote self-care activities
Correct Answer: B
Rationale: The correct answer is B because maintaining hydration and nutrition is crucial for the client's overall well-being and health in stage 3 Alzheimer's. Dehydration and malnutrition can lead to serious complications. Providing a stimulating environment (choice A) may be beneficial but not the highest priority. Setting limits on behavioral disinhibition (choice C) may be challenging due to the progression of the disease. Promoting self-care activities (choice D) may not be feasible as the client's cognitive abilities decline. Maintaining hydration and nutrition is essential for the client's survival and quality of life.