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A nurse wants to assess for suicidal ideation in an elderly patient. Select the best question to begin this assessment.
- A. Are there any things going on in your life that would cause you to consider suicide?'
- B. What are your beliefs about a persons right to take his or her own life?'
- C. Do you think you are vulnerable to developing a depressed mood?'
- D. If you felt suicidal, would you tell someone about your feelings?'
Correct Answer: B
Rationale: This question is clear, direct, and respectful. It will produce information relative to the acceptability of suicide as an option to the patient. If the patient deems suicide unacceptable, no further assessment is necessary. If the patient deems suicide as acceptable, the nurse can continue to assess intent, plan, means to carry out the plan, lethality of the chosen method, and so forth. The other options are less direct, may produce responses that may be unclear, or are appropriate for later in this discussion.
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Which intervention would be the best initial approach for a nurse to take when a young adult patient is verbally abusive?
- A. Ask the patient to define 'verbally abusive language.'
- B. Provide the patient with examples of assertive communication.
- C. Identify the patient's verbal abuse in order to set standards for future dialogue.
- D. Remove privileges from the patient until communications show less aggression.
Correct Answer: C
Rationale: The correct initial approach is to identify the patient's verbal abuse to set standards for future dialogue. This approach addresses the behavior directly, establishes boundaries, and communicates expectations for respectful communication. Asking the patient to define 'verbally abusive language' (choice A) may not effectively address the current behavior. Providing examples of assertive communication (choice B) may not directly address the abusive behavior. Removing privileges (choice D) may escalate the situation and is not a constructive communication strategy. By identifying the patient's verbal abuse, the nurse can address the behavior effectively and work towards a respectful and therapeutic relationship.
In most anxiety disorders, the person's distress is
- A. focused on a specific situation
- B. related to ordinary life stresses
- C. greatly out of proportion to the situation
- D. based on a physical cause
Correct Answer: C
Rationale: Anxiety disorders feature exaggerated distress disproportionate to the trigger, unlike normal stress.
A high school cheerleader was admitted to the eating disorders unit, having developed hypokalemia as the result of purging. Which of these medications will probably be prescribed for the client?
- A. Potassium.
- B. Calcium gluconate.
- C. Metoclopramide (Reglan).
- D. Ferrous sulfate.
Correct Answer: A
Rationale: Step 1: The client has hypokalemia, indicating low potassium levels due to purging.
Step 2: Potassium is essential for muscle function, including the heart.
Step 3: Correct Answer: A - Potassium will be prescribed to replenish the deficient levels.
Summary: B is incorrect as calcium gluconate is not used to treat hypokalemia. C and D are unrelated to treating low potassium levels.
A salesman has had difficulty holding a job because he accuses co-workers of conspiring to take his sales. Today, he argued with several office mates and threatened to kill one of them. The police were called, and he was brought to the mental health center for evaluation. He has had previous admissions to the unit for stabilization of paranoid schizophrenia. When the nurse meets him, he points at staff in the nursing station and states loudly, 'They're all plotting to destroy me. Isn't that true?' Which would be the most appropriate response?
- A. No, that is not true. People here are trying to help you if you will let them.'
- B. Let's think about it: what reason would people have to want to destroy you?'
- C. Thinking that people want to destroy you must be very frightening.'
- D. That doesn't make sense; staff are health care workers, not murderers.'
Correct Answer: C
Rationale: The correct answer is C because it demonstrates empathy and validates the patient's feelings without agreeing with the delusion. By acknowledging the patient's fear, the nurse can establish trust and rapport, which are crucial in therapeutic communication. This response shows understanding and compassion, helping to de-escalate the situation and provide a supportive environment for the patient.
Choice A is incorrect as it denies the patient's belief and may lead to increased agitation. Choice B is incorrect as it challenges the patient's delusion, which can worsen the situation and lead to further confrontation. Choice D is incorrect as it dismisses the patient's feelings and may cause the patient to become defensive or feel misunderstood.
A nurse is caring for a patient diagnosed with anorexia nervosa. What is the most important intervention during the refeeding phase?
- A. Monitor weight gain and provide a structured meal plan.
- B. Encourage the patient to eat independently without supervision.
- C. Focus on psychological therapy to address emotional issues.
- D. Offer the patient high-calorie, high-fat foods to increase intake.
Correct Answer: A
Rationale: The correct answer is A because during the refeeding phase of anorexia nervosa, monitoring weight gain and providing a structured meal plan are crucial to prevent refeeding syndrome and ensure a safe and gradual increase in caloric intake. This approach helps prevent complications such as electrolyte imbalances and organ dysfunction. Encouraging the patient to eat independently without supervision (B) can be harmful as they may not consume adequate or balanced nutrition. Psychological therapy (C) is important but not the most crucial during the refeeding phase. Offering high-calorie, high-fat foods (D) can lead to rapid weight gain and further complications.