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A patient diagnosed with major depressive disorder has lost 20 pounds in one month, has chronic low self-esteem, and a plan for suicide. The patient has taken antidepressant medication for 1 week. Which nursing intervention has the highest priority?
- A. Implement suicide precautions.
- B. Offer high-calorie snacks and fluids frequently.
- C. Assist the patient to identify three personal strengths.
- D. Observe patient for therapeutic effects of antidepressant medication.
Correct Answer: A
Rationale: Implementing suicide precautions is the only option related to patient safety. The other options, related to nutrition, self-esteem, and medication therapy, are important but are not priorities.
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The client says to the nurse, 'I know I can learn to cope with my family situation. By getting help here at the clinic, I’ll be able to deal with them more effectively, and I won’t be so stressed out all the time.' This client is demonstrating a high level of
- A. hardiness.
- B. resilience.
- C. sense of belonging.
- D. self-efficacy.
Correct Answer: D
Rationale: Self-efficacy reflects belief in one’s ability to affect outcomes (D), shown here by proactive help-seeking. Hardiness (A), resilience (B), and belonging (C) don’t fit as directly.
A Chinese American patient diagnosed with an anxiety disorder says,My problems began when my energy became imbalanced. The nurse asks for the patients ideas about how to treat the imbalance. Which comment would the nurse expect from this patient?
- A. My family will bring special foods to help me get well.
- B. I hope my health care provider will prescribe some medication to help me.
- C. I think I would benefit from talking to other patients with a similar problem.
- D. I would like to have a native healer perform a ceremony to balance my energy.
Correct Answer: A
Rationale: The concept of energy imbalance as a source of illness is an explanatory model familiar to Asian cultures. A source of healing is dietary change to include either hot or cold foods to correct the imbalance. Hot and cold in this case do not refer to thermal properties of the foods. Medication would not be a treatment suggested by a patient with an Eastern worldview. Someone from an indigenous culture may suggest rituals. Group discussion of mental illness would not be appealing to a Chinese American.
The creation of asylums during the 1800s was meant to
- A. improve treatment of mental disorders.
- B. provide food and shelter for the mentally ill.
- C. punish people with mental illness who were believed to be possessed.
- D. remove dangerous people with mental illness from the community.
Correct Answer: B
Rationale: The asylum was meant to be a safe haven with food, shelter, and humane treatment for the mentally ill. Asylums were not used to improve treatment of mental disorders or to punish mentally ill people who were believed to be possessed. The asylum was not created to remove the dangerously mentally ill from the community.
Six months ago, a woman had a prophylactic double mastectomy because of a family history of breast cancer. One week ago, this woman learned her husband was involved in an extramarital affair. The woman tearfully says to the nurse, "What else can happen?" What type of crisis is this person experiencing?
- A. Maturational
- B. Mitigation
- C. Situational
- D. Recurring
Correct Answer: C
Rationale: Severe physical or mental illness is a potential cause of a situational crisis. The potential loss of a loved one also serves as a potential cause of a situational crisis. Maturational crisis occurs as an individual arrives at a new stage of development, when old coping styles may be ineffective. No classification of recurring crisis exists. Mitigation refers to attempts to limit a disaster's impact on human health and community function.
During a one-on-one interaction with the nurse, a patient frequently looks nervously at the door. Select the best comment by the nurse regarding this nonverbal communication.
- A. I notice you keep looking toward the door.'
- B. This is our time together. No one is going to interrupt us.'
- C. It looks as if you are eager to end our discussion for today.'
- D. If you are uncomfortable in this room, we can move someplace else.'
Correct Answer: A
Rationale: Making observations and encouraging the patient to describe perceptions are useful therapeutic communication techniques for this situation. The other responses are assumptions made by the nurse.