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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.
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Which patient would the group co-leaders determine is demonstrating Yalom’s therapeutic factor termed universality?
- A. Patient A, who states he realizes he is not the only person who has a problem with loneliness
- B. Patient B, who displays dysfunctional interaction patterns learned in his family of origin
- C. Patient C, who states he finally feels a strong sense of belonging
- D. Patient D, who openly expresses his anger about his work
Correct Answer: A
Rationale: The correct answer is A because universality in Yalom's therapeutic factors refers to the recognition that one is not alone in their struggles. Patient A demonstrates this by acknowledging that others also face loneliness, fostering a sense of commonality and reducing feelings of isolation. In contrast, patient B's dysfunctional patterns do not relate to universality. Patient C's sense of belonging is related to group cohesion, not universality. Patient D's anger expression is not directly linked to recognizing shared experiences.
What is the priority nursing diagnosis for a catatonic patient?
- A. Ineffective coping
- B. Impaired physical mobility
- C. Risk for deficient fluid volume
- D. Impaired social interaction
Correct Answer: C
Rationale: The priority nursing diagnosis for a catatonic patient is Risk for deficient fluid volume (C) because catatonic patients are at risk for dehydration due to decreased fluid intake or inability to meet fluid needs. This diagnosis takes precedence over others as dehydration can lead to serious complications. Ineffective coping (A) may be secondary to the catatonic state but addressing fluid volume is more urgent. Impaired physical mobility (B) and Impaired social interaction (D) are important but not as critical as addressing the risk of dehydration in a catatonic patient.
A teen states, "I miss my dog so much, but if I start crying, I will never stop." This reflects a fear of:
- A. Losing control over her emotions
- B. Losing the support of her friends and family
- C. Embarrassing herself by crying in public
- D. Appearing emotionally immature
Correct Answer: A
Rationale: The correct answer is A because the teen is expressing a fear of losing control over her emotions if she starts crying. This is evident from her belief that she will never stop crying once she starts. Option B (Losing the support of her friends and family) is incorrect as the statement does not suggest concern about losing support. Option C (Embarrassing herself by crying in public) is incorrect as the fear expressed is more about not being able to stop crying rather than embarrassment. Option D (Appearing emotionally immature) is incorrect as there is no indication that the teen is worried about how others perceive her emotional maturity.
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.