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A patient states, "I’m not worth anything. I have negative thoughts about myself. I feel anxious and shaky all the time. Sometimes I feel so sad that I want to go to sleep and never wake up." Which nursing intervention should have the highest priority?
- A. Self-esteem-building activities.
- B. Anxiety self-control measures.
- C. Sleep enhancement activities.
- D. Suicide precautions.
Correct Answer: D
Rationale: The correct answer is D: Suicide precautions. The patient's statement indicates they are experiencing severe depression and suicidal ideation. Suicide precautions should be the highest priority to ensure the patient's safety. This includes removing any potential means of self-harm, constant monitoring, and close supervision. Self-esteem-building activities (A) may be helpful in the long term but are not the immediate priority. Anxiety self-control measures (B) are important but addressing suicidal ideation takes precedence. Sleep enhancement activities (C) are also important but not the highest priority when dealing with suicidal thoughts.
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A patient is scheduled to attend an occupational therapy group to work on the identified goal of “recognizing and using more effective coping techniques.” What measure can the nurse use to continue to support the patient’s attainment of this goal after he returns to the unit?
- A. Praising him for positive behavioral changes
- B. Avoiding setting limits that would increase his anxiety level
- C. Isolating him from more seriously ill patients
- D. Recommending that he avoid group activities for a while
Correct Answer: A
Rationale: The correct answer is A: Praising him for positive behavioral changes. This measure reinforces the patient's use of effective coping techniques, providing positive feedback and motivation. This positive reinforcement encourages the patient to continue utilizing these strategies.
Choices B, C, and D are incorrect:
B: Avoiding setting limits that would increase his anxiety level - This does not actively support the patient's goal of recognizing and using more effective coping techniques.
C: Isolating him from more seriously ill patients - Isolation does not promote the practice of coping techniques and may hinder the patient's social interaction and progress.
D: Recommending that he avoid group activities for a while - Avoiding group activities contradicts the goal of attending occupational therapy groups and working towards improved coping techniques.
Which person has the greatest potential for developing dysfunctional grief?
- A. A teen who has always been one of the popular kids
- B. A widow who regularly states, I really loved my deceased wife
- C. A woman whose husband died as a result of a sudden, traumatic injury
- D. An adult who has dealt with the loss of several family members over the years
Correct Answer: C
Rationale: The correct answer is C because sudden, traumatic deaths can lead to complicated grief reactions. This type of loss can disrupt the individual's ability to process and accept the death, resulting in prolonged and intense emotional distress. The other choices, A, B, and D, do not inherently indicate a higher potential for dysfunctional grief as they do not involve the same level of suddenness or trauma. Teen popularity, expressing love for a deceased spouse, and experiencing multiple losses over time are common situations that may not necessarily lead to dysfunctional grief if appropriate support and coping mechanisms are in place.
A chronically depressed and suicidal client is admitted to a psychiatric unit. The client is scheduled for electroconvulsive therapy (ECT). During the course of ECT, a nurse should recognize the continued need for which critical intervention?
- A. Suicide assessment must continue throughout the ECT course.
- B. Antidepressant medications are contraindicated throughout the ECT course.
- C. Discourage expressions of hopelessness throughout the ECT course.
- D. Encourage a high-caloric diet throughout the ECT course.
Correct Answer: A
Rationale: The correct answer is A because suicide assessment must continue throughout the ECT course to ensure the safety and well-being of the client. During ECT, the client may experience changes in mood and behavior, which could impact their risk of suicide. It is essential for the nurse to monitor and assess the client's suicidal ideation and intent regularly. This ongoing assessment helps in identifying any exacerbation of suicidal thoughts and allows for timely intervention to prevent self-harm.
Choice B is incorrect because antidepressant medications are not necessarily contraindicated throughout the ECT course. In some cases, a client may still require antidepressants in addition to ECT for optimal treatment outcomes.
Choice C is incorrect because it is important to acknowledge and validate the client's feelings of hopelessness rather than discouraging them. By addressing and exploring these feelings, the nurse can provide support and facilitate the client's emotional processing.
Choice D is incorrect because encouraging a high-caloric diet is not directly related to the critical intervention needed during
A physically frail elderly patient with mild cognitive impairments needs services of a facility that can provide supervision and safety as well as recreation and social interaction. The family cares for this patient during the evening and night. Which type of facility should the nurse suggest to meet this patient’s needs?
- A. Skilled nursing facility.
- B. Adult day care program.
- C. Partial hospitalization.
- D. Group home.
Correct Answer: B
Rationale: The correct answer is B: Adult day care program. This option best meets the needs of the patient as it provides supervision, safety, recreation, and social interaction during the day while allowing the family to care for the patient during the evening and night. Adult day care programs offer a structured environment with trained staff to ensure the patient's safety and provide activities to stimulate cognitive function.
Explanation of other choices:
A: Skilled nursing facility - Not ideal as the patient does not require 24-hour nursing care.
C: Partial hospitalization - Typically for individuals needing intensive mental health services, not suitable for this patient's needs.
D: Group home - Usually for individuals who need more permanent residential care, not appropriate for the patient's situation.
A woman whose abusive husband was killed in an automobile accident 3 years earlier continues to idealize him and repeatedly talks about their “wonderful relationship.” Which outcome is most appropriate for the patient? Patient will:
- A. Enlist the emotional support of both family and friends.
- B. Keep a daily journal recording memories of time spent with her husband.
- C. Express both positive and negative feelings about her husband and their life together.
- D. Read information on the affects of physical abuse and the support groups available to her.
Correct Answer: C
Rationale: Rationale:
Choice C is correct because it encourages the patient to express both positive and negative feelings about her husband and their relationship. This approach helps the patient process complex emotions and move towards a more realistic view of the past. It promotes emotional healing and growth by allowing the patient to acknowledge and work through conflicting feelings.
Summary of Incorrect Choices:
A: While emotional support is important, simply enlisting the support of family and friends may not address the underlying issues of idealization and unresolved emotions.
B: Keeping a daily journal may reinforce the idealization of the husband and could potentially hinder the patient's progress in coming to terms with the reality of the relationship.
D: Reading about abuse and support groups may provide information, but it does not directly address the patient's need to explore and express her own feelings about her husband and their relationship.