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A newly admitted patient diagnosed with major depression has gained 20 pounds over a few months and has suicidal ideation. The patient has taken an antidepressant medication for 1 week without remission of symptoms. Select the priority nursing diagnosis.
- A. Imbalanced nutrition: more than body requirements.
- B. Chronic low self-esteem.
- C. Risk for suicide.
- D. Hopelessness.
Correct Answer: C
Rationale: The priority nursing diagnosis in this case is C: Risk for suicide. This is because the patient is exhibiting suicidal ideation, which poses an immediate threat to their safety and well-being. Suicidal ideation requires urgent intervention to ensure the patient's safety. The patient's major depression, weight gain, and lack of symptom remission from the antidepressant medication further emphasize the seriousness of the situation. Choices A, B, and D are not the priority in this scenario as they do not address the immediate risk of harm to the patient. Imbalanced nutrition and chronic low self-esteem are important concerns but do not take precedence over the risk of suicide. Hopelessness, while relevant, is not as urgent as addressing the immediate risk of suicide.
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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 nurse’s most therapeutic intervention.
- A. Assess whether this patient is drinking and driving.
- B. Teach the person about risks for alcoholism and suggest other coping strategies
- C. Advise the person not to drink alone because the risks for injury increase.
- D. Arrange for the person to attend an Alcoholics Anonymous meeting for older adults.
Correct Answer: B
Rationale: The correct answer is B: Teach the person about risks for alcoholism and suggest other coping strategies. This intervention is the most therapeutic because it addresses the underlying issue of using alcohol as a coping mechanism for loneliness and grief. By educating the person about the risks of alcoholism, the nurse can help the individual understand the potential harm of their current coping strategy. Additionally, suggesting alternative coping strategies can provide healthier ways to deal with loneliness and grief, ultimately promoting better overall well-being.
Choice A is incorrect because while assessing drinking and driving is important, it does not directly address the underlying emotional reasons for the alcohol use.
Choice C is incorrect as it focuses on the risks of injury rather than addressing the emotional aspects of the person's drinking behavior.
Choice D is incorrect as it jumps to a specific intervention without first addressing the person's understanding of their alcohol use and providing alternative coping strategies.
A 79-year-old white male tells a nurse, “I have felt very sad lately. I do not have much to live for. My family and friends are all dead, and my own health is failing.” The nurse should analyze this comment as:
- A. Normal pessimism of the elderly.
- B. A call for sympathy
- C. Evidence of risks for suicide.
- D. Normal grieving.
Correct Answer: C
Rationale: The correct answer is C: Evidence of risks for suicide. The statement contains indicators such as feeling very sad, lack of purpose, isolation, and declining health, which are red flags for suicide risk in older adults. It is crucial for healthcare providers to assess and intervene promptly in such cases to prevent harm. Choices A, B, and D are incorrect because they do not address the seriousness of the situation or the potential risk for self-harm.
A nurse plans care based upon the fact that anticipatory grief:
- A. Is associated with fewer expressions of guilt
- B. Prevents development of symptoms of depression
- C. Requires a longer period of time to effect resolution
- D. Prevents development of symptoms of depression
Correct Answer: A
Rationale: The correct answer is A because anticipatory grief allows individuals to gradually accept the impending loss, leading to fewer feelings of guilt. This process helps the individual prepare emotionally and psychologically for the eventual loss, reducing guilt related to not being able to prevent it. Choice B is incorrect because anticipatory grief does not prevent symptoms of depression, but rather helps individuals cope with them. Choice C is incorrect as anticipatory grief does not necessarily require a longer period of time for resolution; it varies for each individual. Choice D is incorrect, as mentioned earlier, because anticipatory grief does not prevent symptoms of depression but helps individuals navigate through them.
What is the basis for the reduction in disturbed thought processes when a patient is administered haloperidol (Haldol)?
- A. Reduction in the number of brain cells that crave dopamin
- B. Dopamine receptors are enhanced, making more dopamine available.
- C. Medication causes an increased cellular production of dopamine
- D. Dopamine receptors are blocked, making dopamine less available.
Correct Answer: D
Rationale: The correct answer is D because haloperidol is a dopamine receptor antagonist. By blocking dopamine receptors, it reduces the activity of dopamine in the brain, which helps in reducing disturbed thought processes. Option A is incorrect as dopamine craving is not related to the mechanism of action of haloperidol. Option B is incorrect as enhancing dopamine receptors would increase dopamine activity, opposite to the intended effect of haloperidol. Option C is incorrect as increasing cellular production of dopamine would also increase dopamine activity, contradicting the purpose of using haloperidol.
The spouse of a patient recently diagnosed with early-stage Alzheimer's disease asks, "Is there anything I can do to help delay the progression of this disease?" Which strategy has the greatest potential for preserving the protective abilities of immune cells related to the disease?
- A. Minimize contact with the public during cold and flu season.
- B. Enroll the patient in an exercise program that meets regularly.
- C. Provide supplements to enhance the patient’s immune system.
- D. Identify creative ways to keep the patient mentally challenged.
Correct Answer: B
Rationale: The correct answer is B: Enroll the patient in an exercise program that meets regularly. Regular exercise has been shown to have numerous benefits for brain health, including improving cognitive function and reducing the risk of cognitive decline. Exercise also helps in maintaining a healthy immune system by promoting the circulation of immune cells throughout the body. This can help support the protective abilities of immune cells related to Alzheimer's disease.
Minimizing contact with the public during cold and flu season (Choice A) may reduce the risk of infections but does not directly address immune cell function. Providing supplements to enhance the patient's immune system (Choice C) may not be supported by scientific evidence and can potentially have adverse effects. Identifying creative ways to keep the patient mentally challenged (Choice D) is beneficial for cognitive health but does not directly target immune cell function as effectively as regular exercise.