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A patient begins a new program to assist with building social skills. In which part of the plan of care should a nurse record the item, "Encourage patient to attend one psychoeducational group daily"?
- A. Assessment
- B. Implementation
- C. Analysis
- D. Evaluation
Correct Answer: B
Rationale: The correct answer is B: Implementation. In the nursing process, implementation involves carrying out the plan of care. Encouraging the patient to attend a psychoeducational group daily is an action that is part of implementing the care plan to improve social skills. This step focuses on putting the plan into action and actively supporting the patient in achieving the desired outcomes.
A: Assessment is incorrect because assessment involves collecting data and information about the patient's condition, not actively implementing interventions.
C: Analysis is incorrect as it involves interpreting and making sense of the assessment data to identify problems and strengths, not implementing interventions.
D: Evaluation is incorrect because it involves assessing the effectiveness of the interventions implemented, not actively carrying out the interventions themselves.
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A new nurse asks, “My elderly patient has Lewy body disease. What should I do about assessing for pain?” Select the best response from the nurse manager.
- A. Ask the patient’s family if they think the patient is experiencing pain.
- B. Use a visual analog scale to help the patient determine the presence and severity of pain.
- C. There are special scales for assessing patients with dementia. Let’s review how to use them.
- D. The perception of pain is diminished by this type of dementia. Focus your assessment on the patient’s mental status.
Correct Answer: C
Rationale: The correct answer is C because Lewy body disease can affect a patient's ability to communicate pain, making specialized pain assessment tools crucial. Special scales designed for patients with dementia can help in accurately assessing pain levels. These tools consider non-verbal cues and behavioral changes that may indicate pain. Asking the patient's family (A) may not always provide an accurate assessment of pain perception. Using a visual analog scale (B) may be challenging for a patient with cognitive impairment. Focusing solely on mental status (D) may overlook important indicators of pain in patients with Lewy body disease.
Planning for a patient with Asperger's disorder will be facilitated if the nurse understands that this disorder is different from autism. The nurse will base care on knowledge that Asperger's disorder is characterized by:
- A. Repetitive patterns of behavior
- B. Age-appropriate language development.
- C. Stereotypic movements and speech patterns
- D. Obsession with objects that move in a spinning motion
Correct Answer: B
Rationale: The correct answer is B: Age-appropriate language development. Asperger's disorder is characterized by normal to above-average language development, whereas autism typically presents with delays or impairments in language skills. This is important for planning care as it influences communication strategies and interventions for individuals with Asperger's.
A: Repetitive patterns of behavior are more indicative of autism, not specific to Asperger's.
C: Stereotypic movements and speech patterns are also more associated with autism and not a defining feature of Asperger's.
D: Obsession with objects that move in a spinning motion is a specific behavior that may be seen in some individuals with autism, but it is not a defining characteristic of Asperger's disorder.
Family and friends rush to offer support to a friend who has lost her teenage son. Which of these persons, through an intended act of kindness, may contribute to prolonging the woman’s grief?
- A. The physician who prescribed antianxiety agents
- B. The nurse who offered to spend the night at her home
- C. The next-door teenager who provided care for the son’s pet
- D. The accountant who assisted with stabilizing financial affairs.
Correct Answer: A
Rationale: The correct answer is A because prescribing antianxiety agents may mask the woman's grief instead of allowing her to process and work through it naturally. This could potentially prolong her grief by avoiding the necessary emotional processing. The other choices, B, C, and D, all involve support that can help the woman cope with her loss in a healthy way. B offers emotional support and companionship, C helps with practical tasks, and D provides assistance in managing practical matters, all of which can facilitate the grieving process rather than prolong it.
To plan care for a patient with a psychiatric disorder, the nurse keeps in mind that the primary nursing role related to therapeutic activities is:
- A. Assisting the patient in accomplishing the activity
- B. Ensuring that the patient will comply with the rules of the activity
- C. Ensuring that the patient can accomplish the activity in a timely manner
- D. Directing and controlling the activities to minimize patient anxiety and confusion
Correct Answer: A
Rationale: Rationale: The correct answer is A: Assisting the patient in accomplishing the activity. This is because the primary nursing role related to therapeutic activities is to support and facilitate the patient in engaging in the activity independently. By assisting the patient, the nurse promotes autonomy and empowerment, which are essential for therapeutic outcomes.
Summary:
- B: Ensuring that the patient will comply with the rules of the activity is incorrect as it focuses on compliance rather than empowering the patient.
- C: Ensuring that the patient can accomplish the activity in a timely manner is incorrect as the focus should be on the patient's ability to engage in the activity, not just the speed.
- D: Directing and controlling the activities to minimize patient anxiety and confusion is incorrect as it doesn't promote the patient's independence and may reinforce dependency.
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.