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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 putting the plan of care into action. Encouraging the patient to attend a psychoeducational group daily is an action that is carried out as part of the plan to build social skills. This step focuses on executing interventions to achieve the desired outcomes. In contrast, assessment (A) involves collecting data, analysis (C) involves interpreting data, and evaluation (D) involves determining the effectiveness of interventions. Therefore, the correct placement for recording this item is in the implementation phase.
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A community health nurse visits an elderly person whose spouse died 6 months ago. Two vodka bottles are in the trash. When the nurse asks about alcohol use, this person says, “I get lonely and drink a little to help me forget.” Select the nurse’s most therapeutic intervention.
- A. Assess whether this patient is drinking and driving.
- B. Teach the person about risks for alcoholism and suggest other coping strategies
- C. Advise the person not to drink alone because the risks for injury increase.
- D. Arrange for the person to attend an Alcoholics Anonymous meeting for older adults.
Correct Answer: B
Rationale: The correct answer is B: Teach the person about risks for alcoholism and suggest other coping strategies. This intervention is the most therapeutic because it addresses the underlying issue of using alcohol as a coping mechanism for loneliness and grief. By educating the person about the risks of alcoholism, the nurse can help the individual understand the potential harm of their current coping strategy. Additionally, suggesting alternative coping strategies can provide healthier ways to deal with loneliness and grief, ultimately promoting better overall well-being.
Choice A is incorrect because while assessing drinking and driving is important, it does not directly address the underlying emotional reasons for the alcohol use.
Choice C is incorrect as it focuses on the risks of injury rather than addressing the emotional aspects of the person's drinking behavior.
Choice D is incorrect as it jumps to a specific intervention without first addressing the person's understanding of their alcohol use and providing alternative coping strategies.
The patient’s daughter was murdered while they were customers in a local bank. Which statements would support the patient’s diagnosis of posttraumatic stress disorder (PTSD)? Select all that apply:
- A. “I feel numb, like a robot going through the motions of existing.”
- B. “I’m so nervous and jump at the slightest noise.”
- C. “I have not slept very well at all since I lost her.”
- D. “I can’t stop reliving the last time I saw her alive.”
Correct Answer: A
Rationale: The correct answer is A because feeling numb and detached from emotions is a common symptom of PTSD known as emotional numbing. This symptom is often seen in individuals who have experienced a traumatic event, such as the murder of a loved one. It is a defense mechanism that helps the person cope with overwhelming emotions.
The other choices are incorrect:
B: Being nervous and easily startled (hypervigilance) is more indicative of the hyperarousal symptom of PTSD, not emotional numbing.
C: Difficulty sleeping is a common symptom of PTSD, known as insomnia, but it does not directly relate to emotional numbing.
D: Reliving the traumatic event through flashbacks or intrusive memories is a symptom of PTSD, but it is not directly related to emotional numbing.
Which statement by a 16-year-old is considered as positive evidence that the family’s involvement in therapy is moving them towards effective functioning?
- A. “My dad has finally stopped giving me advice on how to live my life.”
- B. “I stopped playing football since practice required me to be away from home so often.”
- C. “Since my mother quit her job, she is more available to keep the home running smoothly.”
- D. “Eating dinner with my parents on Sunday nights has helped us be more aware of each other’s needs.”
Correct Answer: D
Rationale: The correct answer is D because it shows positive evidence of improved family dynamics through increased communication and awareness of each other's needs. Eating dinner together signifies a commitment to spending quality time and fostering connections. Choice A indicates a lack of interference but not necessarily improved functioning. Choice B suggests withdrawal from activities, which may not be positive. Choice C implies a sacrifice that may not directly lead to effective functioning.
When a novice nurse asks why the unit has a multidisciplinary approach to therapeutic activities, the nurse should explain that multidisciplinary collaboration:
- A. Reduces the incidence of aggressive behavior by patients
- B. Produces quicker results and earlier discharge to the community
- C. Produces better outcomes than when only one perspective is used
- D. Helps to improve staffing efficiency and resource allocation.
Correct Answer: C
Rationale: Rationale for Correct Answer (C): Multidisciplinary collaboration in therapeutic activities involves the input of professionals from various disciplines, leading to a holistic approach that considers all aspects of a patient's condition. This approach is more likely to result in better outcomes because it combines diverse perspectives, expertise, and skills to address complex patient needs comprehensively.
Summary of Incorrect Choices:
A: Reducing aggressive behavior is not the primary goal of multidisciplinary collaboration in therapeutic activities.
B: While multidisciplinary collaboration may lead to efficient care, the primary focus is on achieving better outcomes rather than quicker discharge.
D: Although improving staffing efficiency and resource allocation may be benefits of multidisciplinary collaboration, the main purpose is to enhance patient care outcomes through diverse perspectives and expertise.
A newly admitted patient diagnosed with major depression has gained 20 pounds over a few months and has suicidal ideation. The patient has taken an antidepressant medication for 1 week without remission of symptoms. Select the priority nursing diagnosis.
- A. Imbalanced nutrition: more than body requirements.
- B. Chronic low self-esteem.
- C. Risk for suicide.
- D. Hopelessness.
Correct Answer: C
Rationale: The priority nursing diagnosis in this case is C: Risk for suicide. This is because the patient is exhibiting suicidal ideation, which poses an immediate threat to their safety and well-being. Suicidal ideation requires urgent intervention to ensure the patient's safety. The patient's major depression, weight gain, and lack of symptom remission from the antidepressant medication further emphasize the seriousness of the situation. Choices A, B, and D are not the priority in this scenario as they do not address the immediate risk of harm to the patient. Imbalanced nutrition and chronic low self-esteem are important concerns but do not take precedence over the risk of suicide. Hopelessness, while relevant, is not as urgent as addressing the immediate risk of suicide.