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A novice nurse tells the assigned mentor, 'I admitted a patient today who has several bizarre delusions. I wanted to tell the patient that the ideas and conclusions simply are not logical. What do you think will happen if I do?' Which reply by the mentor is best?
- A. I think you'll give the patient something to think about.'
- B. The patient will probably incorporate you into the delusions as a persecutor.'
- C. Develop trust using empathy and calmness before pointing out discrepancies.'
- D. Initially, it would be better to go along with the patient's thinking to gain cooperation.'
Correct Answer: C
Rationale: The correct answer is C because it emphasizes the importance of developing trust and rapport with the patient before addressing their delusions. By using empathy and calmness, the nurse can create a safe environment for the patient to feel understood and supported. This approach can help the patient be more receptive to feedback about the discrepancies in their thinking.
Choice A is incorrect because simply giving the patient something to think about may not address the underlying issues causing the delusions.
Choice B is incorrect as it assumes the patient will view the nurse negatively, which may not always be the case.
Choice D is incorrect as it suggests going along with the patient's delusions, which can potentially reinforce and perpetuate their false beliefs.
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A client, age 34, has been physically abused by her husband five times during the past 2 years. During her last discussion with the nurse, the client stated, 'I probably should not keep going back to him.' The nurse is aware that the final decision to leave a batterer:
- A. Is complex and may take time.
- B. Should be made immediately.
- C. Is the responsibility of the nurse.
- D. None of the above.
Correct Answer: A
Rationale: The correct answer is A: Is complex and may take time. The nurse understands that leaving an abusive relationship is a complex process that may take time. The client's statement of awareness indicates progress, but making the final decision to leave a batterer involves various factors such as safety planning, emotional readiness, and support systems. Choice B is incorrect as immediate decision-making can be dangerous without proper planning. Choice C is incorrect as the nurse's role is to support and empower the client but not make decisions for them. Choice D is incorrect as leaving an abuser is a personal decision that requires careful consideration.
A client has been admitted with disorganized type schizophrenia. The nurse observes blunted affect and social isolation. The client occasionally curses or calls another client a 'jerk' without provocation. The nurse asks the client how he is feeling, and he responds, 'Everybody picks on me. They frobitz me.' The best response for the nurse to make would be:
- A. That's really too bad.'
- B. Who do you mean when you say 'everybody'?'
- C. What difference does frobitzing make?'
- D. Why do they frobitz?'
Correct Answer: B
Rationale: The correct answer is B: "Who do you mean when you say 'everybody'?" This response is the best because it acknowledges the client's feelings and seeks clarification. By asking for specifics, the nurse can gain a better understanding of the client's perceptions and experiences, which can help in providing appropriate care and support.
Choice A: "That's really too bad." This response lacks empathy and does not address the client's concerns directly.
Choice C: "What difference does frobitzing make?" This response is dismissive and does not focus on the client's feelings or experiences.
Choice D: "Why do they frobitz?" This response is confrontational and may make the client feel defensive, hindering effective communication and rapport-building.
Which of the following is a critical aspect of nursing care for patients with anorexia nervosa?
- A. Encouraging weight loss to avoid complications from obesity.
- B. Promoting normalization of eating habits and nutritional rehabilitation.
- C. Restricting fluid intake to reduce risk of water retention.
- D. Avoiding any pressure for the patient to gain weight rapidly.
Correct Answer: B
Rationale: The correct answer is B: Promoting normalization of eating habits and nutritional rehabilitation. This is critical in anorexia nervosa treatment to address malnutrition and restore a healthy relationship with food. Encouraging weight loss (A) is inappropriate as these patients are already underweight. Restricting fluid intake (C) can worsen dehydration and electrolyte imbalances. Avoiding pressure for rapid weight gain (D) is important, but the primary focus should be on promoting healthy eating habits and gradual weight restoration. By focusing on normalization of eating habits and nutritional rehabilitation, nurses can help patients with anorexia nervosa recover physically and mentally.
The nurse has been working with a patient diagnosed with schizophrenia who experiences auditory hallucinations. The patient relates, 'When I first heard the voices they said nice things about me. Lately, they've changed and they say bad things.' What information has the least impact on therapeutic patient care at this point in the hospitalization?
- A. Do you trust me to help you with the voices?'
- B. Are the voices commanding you to do something?'
- C. How often during 24 hours do you hear the voices?'
- D. Do you hear the voices if you're busy in noisy environment?'
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
A: Asking about trust in the nurse is not immediately relevant as the patient's primary concern is the change in voice content. Building trust is important but addressing the content of hallucinations takes priority.
B: This is relevant as commanding voices could pose a safety risk.
C: Monitoring frequency helps assess severity and response to treatment.
D: Understanding triggers for hallucinations is important for managing symptoms.
A patient, aged 82 years, has Alzheimer's disease. She lives with her daughter's family and goes to a day care facility on weekdays. The nurse at the day care center noticed the patient was unkempt and had multiple bruises. When the daughter arrived to pick her up, the nurse discussed her observations. The daughter became defensive and said that her mother was very difficult to manage. She stated, "My mother is not my mother anymore. She is confused, and she wanders all night. We have to watch her constantly. Last night I fell asleep, and she fell down the stairs. Sometimes I just cannot bear to care for her."Â Which nursing diagnosis would be most important to address for this patient?
- A. Risk for injury related to impaired cognition, judgment, and coordination and lack of caregiver supervision
- B. Nonadherence related to confusion and disorientation, as evidenced by lack of cooperation
- C. Anxiety related to increasing disorientation, as evidenced by the patient wandering at night
- D. Impaired verbal communication related to brain impairment, as evidenced by the patient's confusion
Correct Answer: A
Rationale: The correct answer is A: Risk for injury related to impaired cognition, judgment, and coordination and lack of caregiver supervision. The rationale is that the patient's Alzheimer's disease has led to impaired cognitive function, making her at risk for injury due to wandering and falls. The daughter's lack of supervision and inability to manage the patient's needs further exacerbate this risk. Choices B, C, and D are incorrect because they do not directly address the immediate safety concern of the patient being at risk for injury. Nonadherence, anxiety, and impaired communication are important issues but do not take precedence over the patient's safety in this context.