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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. What are your beliefs about a person’s right to take his or her own life?
- B. Are there any things going on in your life that would cause you to consider suicide?
- 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: his open-ended question directly addresses the patient’s thoughts about suicide in the context of their current life situation, giving them an opportunity to express any concerns or ideations.
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In the ECT treatment preparation period the morning of treatment, the nurse should:
- A. Assess the patient’s cognitive function.
- B. Have the patient exercise for 10 minutes.
- C. Ensure that the patient produces a urine sample.
- D. Allow the patient to eat a heavy meal if they are hungry.
Correct Answer: A
Rationale: The correct action during the ECT treatment preparation period the morning of treatment is to adequately hydrate the patient. Ensuring that the patient is properly hydrated before the procedure is crucial for their safety and well-being. Hydration helps optimize the effects of the treatment and can support the patient's recovery post-treatment. It is important to maintain the patient's fluid balance as ECT can sometimes cause side effects such as nausea, headache, and muscle aches, which can be worsened if the patient is not adequately hydrated. Additionally, hydration can help prevent complications such as dehydration or electrolyte imbalances during and after the ECT procedure.
Which patient would the nurse determine to be at highest risk for dysfunctional grief? The patient:
- A. Whose 16-year-old daughter was raped and killed while going on an errand for the patient
- B. Whose 86-year-old mother, with whom she has shared her home, died after a long illness.
- C. Who attended a support group and had been assisted by hospice to care for her terminally ill husband
- D. Who attended a bereavement group, where she learned to express feelings after the deaths of her twin daughters
Correct Answer: A
Rationale: The patient whose 16-year-old daughter was raped and killed while going on an errand for the patient would be determined to be at highest risk for dysfunctional grief. This traumatic event involves sudden and violent loss of a child, which can lead to complicated or dysfunctional grief reactions. The circumstances of the death, involving violence, unexpectedness, and the close relationship with the deceased, can significantly impact the grieving process. The patient may struggle with intense emotions, guilt, anger, and unresolved trauma, making them more vulnerable to experiencing dysfunctional grief. It is essential for healthcare professionals to provide appropriate support and interventions to help the patient navigate through this complex grieving process.
A nurse, leading an inpatient group dealing with women’s issues, identifies a patient who is assuming the role of aggressor. Which behavior characterizes this role?
- A. Mediating conflicts and disagreements
- B. Criticizing the contributions of others
- C. Seeking a position between contending sides
- D. Remaining quiet and refraining from participating in group discussions
Correct Answer: B
Rationale: In a group setting, a patient assuming the role of aggressor typically exhibits behaviors such as criticizing the contributions of others, being hostile, confrontational, and attempting to assert dominance. This behavior can create a negative and hostile environment in the group, undermining the therapeutic process. It is important for the nurse to recognize and address this behavior in order to promote a safe and supportive atmosphere for all group members to participate and benefit from the sessions.
A patient is being seen for symptoms of insomnia and significant weight loss that has occurred during the 2 months since her husband’s death. What is the purpose of the query, “Describe how it has been for you since your husband died?”
- A. To display an attitude of concern and sympathy to the patient
- B. To learn whether the patient has a significant support system
- C. To rule out factors that may interfere with diagnosing her illness
- D. To determine the risk for pathologic grief and the need for grief therapy
Correct Answer: D
Rationale: The purpose of the query "Describe how it has been for you since your husband died?" is to determine the risk for pathologic grief and the need for grief therapy. The patient is experiencing symptoms of insomnia and significant weight loss following her husband's death, which could indicate complicated or pathologic grief. By asking this open-ended question, the healthcare provider can gain insight into the patient's emotional well-being, coping mechanisms, and overall adjustment to the loss. The response can help assess whether the patient might benefit from additional support or interventions, such as grief therapy, to help her navigate through the grieving process in a healthy manner. It is essential to identify and address any potential complications related to grieving to provide appropriate care and support to the patient.
According to Piaget, which of the following would the nurse consider normal when assessing a 6-year-old?
- A. Playing with an imaginary friend
- B. Talking about their best friend
- C. Enjoying putting puzzles together
- D. Knowing it’s wrong to tell a lie
Correct Answer: C
Rationale:
At 6 years old, children are typically in the concrete operational stage of development, characterized by logical thinking and enjoyment of problem-solving activities like puzzles.