Nokea
A patient moving from chair to chair in the day room and pacing in the hallway repeatedly, rapidly, and for extended periods is likely demonstrating ______, and the nurse should ______.
- A. a dystonic reaction"¦administer PRN IM benztropine (Cogentin)
- B. anxiety"¦ teach and guide the patient to use relaxation exercises
- C. akathisia"¦administer PRN diphenhydramine (Benadryl) PO
- D. tardive dyskinesia"¦recommend a change in medication
Correct Answer: C
Rationale: The correct answer is C: akathisia"¦administer PRN diphenhydramine (Benadryl) PO. Akathisia is characterized by restlessness and an inability to sit still. Administering diphenhydramine can help alleviate these symptoms. A is incorrect because dystonic reactions present with muscle spasms and abnormal postures, not restlessness. B is incorrect as anxiety does not typically manifest as physical restlessness. D is incorrect as tardive dyskinesia involves involuntary movements of the face and body, not restlessness.
You may also like to solve these questions
An adult consulted a nurse practitioner because of an inability to achieve orgasm for 2 years, despite having been sexually active. This adult was frustrated and expressed concerns about the relationship with the sexual partner. Which documentation best indicates the treatment was successful?
- A. No complaints related to sexual function; to return next week.
- B. Patient reports achieving orgasm last week; seems very happy.
- C. Reports satisfaction with sexual encounters; feels partner is supportive.
- D. Reports achieving orgasm occasionally; relationship with partner is adequate.
Correct Answer: C
Rationale: Step 1: Choice C indicates satisfaction with sexual encounters and feeling supported by the partner, which suggest a positive outcome in addressing the inability to achieve orgasm and concerns about the relationship.
Step 2: The patient feeling satisfied and supported signifies improvement in sexual function and relationship dynamics.
Step 3: This documentation reflects a holistic approach to addressing the patient's concerns, focusing on emotional well-being and relationship quality.
Step 4: Overall, choice C demonstrates a comprehensive resolution to the patient's initial complaints and indicates successful treatment.
Summary:
Choice C is the correct answer as it shows improvement in both sexual function and relationship satisfaction. Choices A, B, and D do not address the patient's concerns about the relationship or emotional well-being, making them less appropriate indicators of treatment success.
According to family systems theory, removing the 'identified patient' from the environment most likely causes the:
- A. patient to decompensate, due to the loss of their support system
- B. patient to significantly improve, often with minimal or no additional therapy
- C. remaining family members to decompensate, as evidenced by new dysfunctional behavior
- D. remaining family members to lose motivation and withdraw from therapy
Correct Answer: C
Rationale: Family systems theory posits that removing the 'patient' shifts dysfunction to other members, revealing underlying systemic issues.
A patient is noted to be bending over backward in the group room. A peer asks what he is doing, and he replies, 'People say they are bending over backwards to help me, so I am bending over backwards to help myself.' This is an example of:
- A. abstract thinking.
- B. concrete thinking.
- C. impaired reality testing.
- D. boundary impairment.
Correct Answer: B
Rationale: The correct answer is B: concrete thinking. Concrete thinking refers to interpreting things in a literal or straightforward manner without grasping abstract concepts or metaphors. In this scenario, the patient is taking the expression "bending over backward" literally, demonstrating a lack of understanding of its figurative meaning.
A: Abstract thinking involves understanding complex concepts and interpreting information beyond the literal meaning. The patient's response does not demonstrate abstract thinking.
C: Impaired reality testing refers to an inability to distinguish between what is real and what is not. The patient's response does not suggest a detachment from reality.
D: Boundary impairment involves difficulty in recognizing and maintaining personal boundaries. The patient's response does not relate to boundary issues.
In summary, the patient's literal interpretation of the expression "bending over backward" reflects concrete thinking, making choice B the correct answer.
Which nursing progress note would most suggest that the treatment plan of a severely depressed and withdrawn patient has been effective?
- A. Slept 6 hours straight, sang with activity group, eager to see grandchild.
- B. Slept 8 hours, attended craft group, ate half of lunch, denies suicidal ideation.
- C. Slept 10 hours, personal hygiene adequate with assistance, lost one pound.
- D. Slept 7 hours on and off, reports "food has no taste", no self-harm noted.
Correct Answer: A
Rationale: The correct answer is A because it indicates positive changes in mood, engagement, and social interaction, which are key indicators of effective treatment for severe depression. Sleeping 6 hours straight shows improved sleep patterns, singing with the activity group reflects increased participation and enjoyment, and being eager to see the grandchild demonstrates a renewed sense of joy and connection.
Choice B is incorrect because although the patient denies suicidal ideation, the level of activity and engagement is not as high as in choice A. Choice C is incorrect as the focus is on physical aspects rather than emotional well-being and social interaction. Choice D is incorrect because the patient still shows signs of depression such as lack of appetite and loss of interest in activities.
The highest priority for assessment by nurses caring for older adults who self-administer medications is
- A. use of multiple drugs with anticholinergic effects.
- B. overuse of medications for erectile dysfunction.
- C. missed doses of medications for arthritis.
- D. trading medications with acquaintances.
Correct Answer: A
Rationale: The correct answer is A: use of multiple drugs with anticholinergic effects. This is the highest priority because anticholinergic medications are commonly prescribed to older adults and can lead to serious adverse effects such as confusion, memory issues, and falls. Nurses must assess for these effects to prevent harm.
Choice B (overuse of medications for erectile dysfunction) is not as high a priority as anticholinergic effects, as it is not as common and typically has less immediate serious consequences for older adults.
Choice C (missed doses of medications for arthritis) is important but not as critical as assessing for anticholinergic effects, as missed doses can generally be managed through education and adherence support.
Choice D (trading medications with acquaintances) is a serious concern but is not as high a priority as assessing for anticholinergic effects, as the immediate risks associated with anticholinergic medications are more severe.