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A nurse assesses an elderly patient. The nurse should complete the Geriatric Depression Scale if the patient answers which question affirmatively.
- A. Would you say your mood is often sad?
- B. Are you having any trouble with your memory?
- C. Have you noticed an increase in your alcohol use?
- D. Do you often experience moderate to severe pain?
Correct Answer: A
Rationale: The correct answer is A because assessing the patient's mood is crucial in detecting depression in the elderly. Depression is common in older adults and can often go undiagnosed. By asking about their mood, the nurse can identify potential signs of depression early on. Choices B, C, and D are incorrect as they do not directly relate to assessing depression. Memory issues (B) may indicate cognitive decline, increased alcohol use (C) could suggest substance abuse, and pain (D) may signal physical health concerns, but they are not specific indicators of depression in the elderly.
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A victim of spousal abuse comes to the emergency department for treatment of a broken arm. She appears hypervigilant and anxious and admits to sleep disturbance when the nurse questions the dark circles under her eyes. She reluctantly tells the nurse the abuse usually occurs when the husband has been drinking, although she concedes he is always jealous and controlling. She is a stay-at-home mother of two preschool children. The family has lived in this town for 1 month. The patient states she has fleetingly considered suicide but must stay alive to care for her children and work her way out of the abusive relationship. She denies any further suicidal thoughts. The nurse should document in the medical record that: (Select all that apply.)
- A. Signs of high anxiety and chronic stress are present.
- B. The patient relies on the perpetrator for basic needs.
- C. The patient has a history of suicidal ideation.
- D. None of the above.
Correct Answer: A
Rationale: The correct answer is A: Signs of high anxiety and chronic stress are present.
Rationale:
1. The patient displaying hypervigilance, anxiety, sleep disturbances, and dark circles under her eyes are indicators of high anxiety and chronic stress, common in victims of abuse.
2. Mentioning abuse occurring when the husband drinks, his jealousy, and control further support the presence of chronic stress and anxiety.
3. The patient's fleeting suicidal thoughts are a response to the abusive situation, not indicative of a history of suicidal ideation.
Summary:
B: The patient relying on the perpetrator for basic needs is not supported by the information provided.
C: There is no indication of a history of suicidal ideation, as the patient's thoughts are tied to her children and escaping the abusive relationship.
A client with moderate to severe dementia does not remember her son's name. The son repeatedly questions the mother when he visits the dementia facility, asking, 'Do you know my name?' The mother invariably becomes agitated. The nurse can most effectively intervene by explaining to the son:
- A. Your mother is angry with you and is punishing you by 'forgetting' who you are. Be patient and she'll get over it.'
- B. I know it is difficult for you, but your mother's dementia is severe and she cannot retain information even for short periods of time. She senses your distress and becomes agitated.'
- C. Although it's a strain for you, you will need to reorient your mother as often as you can, during the time you are with her. With repetition, she may be able to understand and recall what you are saying.'
- D. Because you become so distressed, it might be better if you come to see your mother only once a week and stay for only a short time.'
Correct Answer: B
Rationale: Rationale:
1. Correct Answer (B): Explains the son's mother's inability to retain information due to severe dementia, causing agitation. Validates son's feelings and provides insight into the mother's behavior.
2. Incorrect Answer (A): Falsely suggests the mother is punishing the son by forgetting, potentially causing misunderstanding and blame.
3. Incorrect Answer (C): Implies the son should solely focus on reorienting the mother, overlooking the emotional impact and distress caused by repetitive questioning.
4. Incorrect Answer (D): Suggests limiting visits based on the son's distress, rather than addressing the root cause of agitation caused by the mother's dementia.
The mother of a 2-year-old tells the nurse at the well-child clinic that her child likes to take a blanket wherever he goes. The mother asks if she should take the blanket away from the child. The nurse counsels the mother to allow the child to have the blanket because it reminds him of his mother and comforts him. The basis for this counseling is:
- A. Mahler's theory of object relations
- B. Freud's developmental theory
- C. Kernberg's conceptualization object constancy
- D. Sullivan's theory of 'good me'
Correct Answer: A
Rationale: The correct answer is A: Mahler's theory of object relations. Mahler's theory focuses on the development of a child's sense of self and relationships. In the scenario provided, the child's attachment to the blanket can be seen as a transitional object, which is a source of comfort and security, similar to the mother. This concept aligns with Mahler's theory that objects like blankets can serve as symbols of the mother and aid in the child's emotional development.
Incorrect choices:
B: Freud's developmental theory primarily focuses on psychosexual stages of development, which do not directly address the use of transitional objects.
C: Kernberg's conceptualization of object constancy pertains to personality disorders and the ability to maintain stable relationships, not the use of transitional objects.
D: Sullivan's theory of 'good me' is centered around interpersonal relationships and self-esteem, which are not directly related to the use of transitional objects in early childhood development.
Which patient statement would not be considered a potential risk factor for family-directed violence?
- A. My parents certainly believed 'spare the rod, spoil the child.'
- B. My parents are ashamed that I had to get a part-time job to help buy food.'
- C. My family thinks I'm just a burden, but they'll be sorry that they felt that way.'
- D. When my spouse gets upset he tells me I'm no longer attractive because I've gained weight.'
Correct Answer: B
Rationale: The correct answer is B because having to get a part-time job to help buy food may indicate financial strain within the family but does not directly relate to family-directed violence. Choice A indicates a potential history of physical discipline, which is a risk factor for violence. Choice C suggests feelings of resentment and potential retaliation, indicating a risk factor. Choice D hints at emotional abuse through manipulation and body shaming, also a risk factor. Therefore, B is the only statement that does not directly indicate a risk factor for family-directed violence.
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.