Nokea
A patient is currently in an abusive relationship with the father of her only child and tells a nurse that her partner 'is really sorry for hitting me and wants to come back and be part of the family again.' The nurse should provide which intervention?
- A. Share with the patient that abusers seldom voluntarily stop abusing.
- B. Identify groups that focus on treatment for individuals who are abusive.
- C. Tell the patient to continue the relationship, but focus on how to minimize the abuse.
- D. Tell the patient's partner that any continued abuse will be reported to the police.
Correct Answer: B
Rationale: The correct answer is B: Identify groups that focus on treatment for individuals who are abusive. This intervention is appropriate because it addresses the root cause of the abusive behavior, which is the partner's abusive tendencies. By connecting the abuser to groups that specialize in treating abusive behavior, there is a chance for change and rehabilitation.
A: Sharing with the patient that abusers seldom voluntarily stop abusing may not be helpful as it does not provide a proactive solution to address the abusive behavior.
C: Telling the patient to continue the relationship and focus on minimizing the abuse is dangerous as it normalizes and enables the abusive behavior, putting the patient at further risk.
D: Threatening the patient's partner with reporting to the police may escalate the situation and put the patient at higher risk of harm. It does not address the underlying issue of the partner's abusive behavior.
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The nurse is administering haloperidol (Haldol) to a client experiencing delusions and hallucinations associated with schizophrenia. The nurse can expect symptom abatement as a result of the drug's action to:
- A. Reduce the number of brain cells that crave dopamine
- B. Block dopamine receptors, making dopamine less available
- C. Enhance dopamine receptors, making more dopamine available
- D. Cause increased cellular production of dopamine
Correct Answer: B
Rationale: The correct answer is B because haloperidol is a typical antipsychotic that works by blocking dopamine receptors in the brain. By blocking these receptors, haloperidol reduces the effects of excess dopamine, which is known to contribute to symptoms of schizophrenia such as delusions and hallucinations. This action helps alleviate the positive symptoms of schizophrenia.
Choice A is incorrect because haloperidol does not reduce the number of brain cells that crave dopamine; it acts on the receptors themselves. Choice C is incorrect because enhancing dopamine receptors would lead to an increase in the effects of dopamine, worsening symptoms. Choice D is incorrect because haloperidol does not cause increased cellular production of dopamine; it blocks dopamine receptors instead.
The home care nurse assessed a client with a history of dementia who had a herniorrhaphy at an ambulatory surgical center the previous day. The client lives in a senior retirement community and has no close family. The nurse assesses mild dysphasia. The client cannot remember why he has a bandage. He thinks he is in the army and that it is 1950. Appropriate planning for the client should include:
- A. Arranging an appointment at a geriatric assessment program; OT referral for swallowing therapy; teaching to manage public transportation
- B. Attending English class to improve speech; transferring finances to a conservator; employing an aide to help with medications
- C. Arranging Meals on Wheels, attending speech therapy; relocation to a skilled nursing facility if no improvement in 1 month
- D. Assessing diet and meal preparation; assessing environment for safety problems; referral to a dementia program
Correct Answer: D
Rationale: The correct answer, D, is the most appropriate plan because it addresses the client's current needs and safety concerns. Firstly, assessing diet and meal preparation is important due to the client's dysphasia, which may impact their ability to eat safely. Secondly, assessing the environment for safety problems is crucial as the client has dementia and may be at risk of accidents. Lastly, referral to a dementia program is necessary to provide specialized care and support for the client's condition.
Choices A, B, and C are incorrect because they do not directly address the specific needs of the client in terms of dementia, dysphasia, and safety concerns. They focus on unrelated interventions that are not as critical in this scenario.
A patient states that unit staff members have been avoiding them since an attempt to self-mutilate. The psychiatric-mental health nurse's most appropriate response is to:
- A. apologize for the staff's behavior
- B. explain that feelings of rejection are typical after self-mutilation
- C. listen, redirect the patient to their feelings, and explore the issue with the staff
- D. report the matter to the nurse manager
Correct Answer: C
Rationale: Listening validates the patient, redirecting focuses on their emotions, and exploring with staff addresses care quality.
A patient has recently been under significant stress and worked long hours. At home, the patient watches television and eats until going to bed. The patient is too tired to exercise and has gained 25 pounds in 1 month. A desired outcome for the patient is to recognize anxiety that precedes binge eating and reduce it. Which intervention addresses the outcome?
- A. Teach stress-reduction techniques such as relaxation and imagery.
- B. Encourage the patient to design and implement an exercise program.
- C. Explore ways in which the patient may feel more in control of the environment.
- D. Encourage the patient to attend a support group such as Overeaters Anonymous.
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. Teaching stress-reduction techniques (relaxation, imagery) helps patient identify anxiety triggers leading to binge eating.
2. By recognizing anxiety, patient can interrupt pattern of mindless eating and address root cause.
3. Relaxation techniques empower patient to cope effectively without turning to food.
4. Encouraging exercise (choice B) may not directly address underlying anxiety and binge eating triggers.
5. Exploring control over the environment (choice C) does not necessarily address emotional aspects of binge eating.
6. Attending a support group (choice D) may provide peer support but doesn't focus on recognizing and reducing anxiety triggers.
A person who is the caregiver of a parent with early-to-middle-stage Alzheimer disease is concerned about possible episodes of incontinence. What strategy should the nurse suggest?
- A. Limiting the patient's fluid intake to 1000 ml daily
- B. Discussing the use of an indwelling catheter with the physician
- C. Putting plastic coverings on the beds, upholstered chairs, and sofas
- D. Taking the patient to the bathroom at least every 2 hours when the patient is awake
Correct Answer: D
Rationale: The correct answer is D: Taking the patient to the bathroom at least every 2 hours when the patient is awake. This strategy helps prevent episodes of incontinence by ensuring the patient has regular opportunities to void. It promotes continence through scheduled toileting, maintaining the patient's dignity and preventing accidents.
Choice A is incorrect as restricting fluid intake can lead to dehydration and other health issues. Choice B is incorrect because indwelling catheters are not recommended for managing incontinence in Alzheimer's patients due to the risk of urinary tract infections. Choice C is incorrect as it only addresses the aftermath of incontinence, not the prevention of it.