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A nurse is caring for a patient who is confused, disoriented in all three spheres, and experiencing visual hallucinations. While preparing to provide personal care, the nurse should:
- A. ask the patient, "Do you remember who I am?"Â
- B. speak minimally so as not to disturb the patient.
- C. pat the patient on the forearm and say, "Let's get started."Â
- D. explain to the patient what will happen during the care.
Correct Answer: D
Rationale: The correct answer is D because explaining to the patient what will happen during care is essential to provide a sense of orientation and reduce anxiety in a confused patient. This approach helps the patient understand the situation and feel more in control, which can decrease agitation. Choice A is incorrect as the patient's memory deficit may lead to further confusion. Choice B is incorrect as minimal communication may not address the patient's needs. Choice C is incorrect as physical touch without explanation may escalate the patient's hallucinations.
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The spouse of a man being treated with sertraline (Zoloft) calls to report that he had a grand mal seizure. Prior to the seizure, he had seemed confused and his forehead felt hot. The man does not have a seizure-disorder history. Which action should the nurse direct the spouse to take?
- A. Monitor the patient and notify the clinic if there are more seizures.
- B. Hold all medications and call 911 for transportation to the hospital.
- C. Hold tonight's sertraline and encourage him to drink more fluids.
- D. Administer an antipyretic drug to lower his fever and prevent seizures.
Correct Answer: B
Rationale: Step 1: The man had a grand mal seizure, confusion, and a hot forehead, which are signs of serotonin syndrome, a serious side effect of sertraline.
Step 2: The nurse should direct the spouse to hold all medications to prevent further serotonin syndrome symptoms.
Step 3: Calling 911 for immediate transportation to the hospital is crucial for prompt evaluation and treatment of the seizure and serotonin syndrome.
Step 4: This action ensures the man receives appropriate medical care to address the seizure and manage the potential serotonin syndrome.
Summary:
- Choice A is incorrect as monitoring the patient at home is not sufficient for a serious medical emergency like serotonin syndrome.
- Choice C is incorrect as simply holding tonight's sertraline and encouraging fluids does not address the immediate need for medical intervention.
- Choice D is incorrect as administering an antipyretic drug does not address the underlying cause of the seizure and confusion, which is serotonin syndrome.
A patient with schizophrenia tells the nurse 'I don't know, it's just all the same. You never know. It comes, it goes, it blows away. Get it?' The best response for the nurse to make would be:
- A. Nothing you are saying is clear; you are not making sense.'
- B. Yes, life can be like that sometimes, very confusing.'
- C. Try to organize your thoughts and then tell me again.'
- D. I am having difficulty understanding what you are saying.'
Correct Answer: D
Rationale: The correct answer is D because it reflects active listening and acknowledges the patient's communication difficulties without being dismissive. By stating difficulty in understanding, the nurse shows empathy and openness to further clarification. Choice A is incorrect as it may be perceived as judgmental. Choice B is incorrect as it does not address the patient's communication challenges. Choice C is incorrect as it places the responsibility solely on the patient without offering support.
The Omnibus Budget Reconciliation Act (OBRA) provides standards of care for which of the following:
- A. Very young
- B. Older adults
- C. Those who have certain intellectual communication difficulties
- D. Those without medical insurance
Correct Answer: B
Rationale: OBRA provides regulations for proper assessment of the elderly (B); for this reason, registered nurses have to provide the initial physical assessment.
Which of the following is an effective communication technique that should be included in the teaching plan for the family members of a woman in whom Alzheimer's disease has been diagnosed recently?
- A. Use simple, familiar words, along with short and simple sentences.
- B. If the client tends to pace a lot, be sure to encourage her to sit during interactions.
- C. If she doesn't understand the communication, change key words.
- D. Use hand gestures when speaking to try to explain what is being said.
Correct Answer: A
Rationale: The correct answer is A: Use simple, familiar words, along with short and simple sentences. This is an effective communication technique for individuals with Alzheimer's disease as it helps in enhancing understanding and reduces confusion. Complex language or sentences may be difficult for the patient to comprehend.
Choice B is incorrect because encouraging the client to sit during interactions does not directly relate to effective communication techniques. Choice C is incorrect as changing key words can lead to further confusion and may not aid in understanding. Choice D is incorrect because using hand gestures may not always effectively convey the message and can potentially cause more confusion for individuals with Alzheimer's disease.
A client is admitted to a day hospital following an episode in which he purchased a gun to use while standing guard over his property to prevent a neighbor from erecting a boundary fence. His wife describes him as distrustful of the motives of others and often interpreting others' motives as threats. She mentions that one time he accused her of having an affair with a neighbor with whom she chatted occasionally. The care plan will list the priority outcome as 'Client will:
- A. admit his action was excessive based on the circumstance.
- B. write the neighbor a letter of apology.
- C. demonstrate trust in the nurse.
- D. identify positive role models.'
Correct Answer: C
Rationale: The correct answer is C: demonstrate trust in the nurse. This is the priority outcome because the client's lack of trust and tendency to perceive threats need to be addressed first. By demonstrating trust in the nurse, the client can begin to develop a therapeutic relationship, which is essential for addressing his distrustful behavior and interpreting threats. This outcome focuses on building rapport and establishing a foundation for therapeutic interventions.
Choice A is incorrect because admitting his action was excessive may not address the underlying issues of distrust and misinterpretation of motives. Choice B is incorrect as it does not address the client's core issues and may not be appropriate in this context. Choice D is also incorrect as identifying positive role models is not a priority when the client's trust and perception issues need immediate attention.