Nokea
A patient is in a smoking cessation program that encourages self-control therapy interventions. Which intervention would the nurse suggest?
- A. Limiting smoking to certain times of the day
- B. Keeping a behavioral diary that tracks when the patient smokes
- C. Identifying factors that encouraged the patient to start smoking
- D. Making plans to spend money saved when smoking stops
Correct Answer: B
Rationale: Self-control therapy emphasizes self-monitoring to identify triggers and patterns, enabling the patient to implement strategies for behavioral change.
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The desired outcome for a patient experiencing insomnia is, "Patient will sleep for a minimum of 5 hours nightly within 7 days." At the end of 7 days, review of sleep data shows the patient sleeps an average of 4 hours nightly and takes a 2-hour afternoon nap. What is the nurse’s next action?
- A. Continue the current plan without changes.
- B. Remove this nursing diagnosis from the plan of care.
- C. Write a new nursing diagnosis that better reflects the problem.
- D. Examine interventions for possible revision of the target date.
Correct Answer: D
Rationale: When goals are partially met, the plan of care should be re-evaluated, and adjustments should be made to interventions or timelines.
When leading a therapeutic group, the nurse demonstrates an understanding of the need to act as the group’s executive when:
- A. Restating rules when a new member joins
- B. Being available to orient the new members
- C. Helping a member defuse the anger they are experiencing
- D. Offering personal opinions on group topics
Correct Answer: A
Rationale: When leading a therapeutic group, the nurse's role as the group's executive involves setting and maintaining boundaries, ensuring adherence to the group's rules, and creating a safe and structured environment for all members. Restating rules when a new member joins helps to establish expectations and maintain consistency within the group. It allows the nurse to assert authority and guide the group in a direction that is conducive to therapeutic progress. By upholding the rules and boundaries of the group, the nurse helps to create a sense of safety and trust among the members, allowing for open and productive communication and shared growth.
A 76-year-old is regressed, indifferent, and responds to others only when they initiate an interaction. What form of group therapy would be most useful to promote resocialization?
- A. Remotivation
- B. Activity group
- C. Psychotherapy
- D. Reminiscence (life review)
Correct Answer: A
Rationale: Remotivation therapy focuses on stimulating engagement and interaction in patients who are socially withdrawn or have limited emotional responses. It helps the individual reconnect with their environment and others.
In the elderly, administering medication is a great concern for the nurse since these patients are more prone to side effects. The primary cause of this is:
- A. Altered circulation and renal function
- B. Accelerated gastrointestinal system
- C. Enlarged Lymph nodes
- D. Musculoskeletal system weakness
Correct Answer: A
Rationale: Aging causes decreased renal and hepatic function, leading to slower metabolism and clearance of drugs, making older adults more vulnerable to drug toxicity and side effects. Other options, such as accelerated gastrointestinal function, are incorrect as GI motility often slows with age.
A friend says to a nurse, “I am not going to get vaccines for my baby. I hear that vaccines cause autism.” The nurse’s best reply is:
- A. The exact cause of autism is not really known
- B. It’s believed that autism is really a result of birth trauma
- C. There is no conclusive evidence to connect autism to vaccinations.
- D. Please tell me more about where you got that information about autism?
Correct Answer: C
Rationale: This response provides factual, evidence-based information to address the common misconception linking vaccines to autism. It is clear and reassuring for the parent.