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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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When making a distinction as to whether an elderly patient has confusion related to delirium or another problem, what information would be of particular value?
- A. Evidence of spasticity or flaccidity
- B. The patient’s level of motor activity
- C. Medications the patient has recently taken
- D. Level of preoccupation with somatic symptoms
Correct Answer: C
Rationale: The correct answer is C: Medications the patient has recently taken. This information is crucial because certain medications can cause symptoms of delirium or exacerbate confusion in elderly patients. By reviewing the patient's recent medications, healthcare providers can identify potential drug-induced causes of confusion and adjust the treatment accordingly.
Choice A (Evidence of spasticity or flaccidity) is incorrect because these symptoms are more related to neurological conditions such as stroke or spinal cord injury, not specifically delirium.
Choice B (The patient’s level of motor activity) is not as relevant in distinguishing delirium from other problems as medication history, as motor activity can be influenced by various factors.
Choice D (Level of preoccupation with somatic symptoms) is also less relevant compared to medication history in differentiating delirium, as somatic symptoms may not always directly indicate the underlying cause of confusion in elderly patients.
Which statement best defines the nurse’s initial role as the patient’s source of help in addressing interpersonal problems?
- A. “I’ll work with your doctor to help you get better.”
- B. “I’ll be working with you to help solve your marital troubles.”
- C. “Your medications will help you feel better as soon as they take effect.”
- D. To direct the patient to other professionals for addressing interpersonal issues
Correct Answer: B
Rationale: The correct answer is B because it emphasizes the nurse's role in actively working with the patient to address interpersonal problems. The nurse's initial role is to provide support and assistance to the patient in resolving their issues collaboratively. Choice A focuses on medical treatment and collaboration with the doctor, not specifically addressing interpersonal problems. Choice C solely emphasizes the role of medications in improving the patient's well-being, neglecting the interpersonal aspect. Choice D suggests passing off the responsibility to other professionals, which contradicts the nurse's initial role as a source of help for the patient. In summary, choice B is correct because it highlights the nurse's active involvement in solving the patient's interpersonal problems.
Nursing preparation for a client undergoing electroconvulsive therapy (ECT) resemble those used for general anesthesia. The nurse should follow these steps for this procedure (place in the order they will occur):
- A. Monitor the patients vital signs before the procedure.
- B. Medicate as prior to procedure if ordered.
- C. Educate patient and patients family.
- D. Check a signed consent
Correct Answer: C
Rationale: Rationale:
1. Educating the patient and family is crucial as it helps alleviate anxiety and ensures informed consent.
2. Monitoring vital signs (A) should be done before, during, and after the procedure, not necessarily in a specific order.
3. Medication administration (B) should be based on physician's orders but is not the initial step.
4. Checking a signed consent (D) is important but typically done before proceeding with any procedure, not necessarily in a specific order.
When a patient asks the nurse, “How can jolting me with an electrical shock possibly do me any good?” the answer most reflective of current biologic theory would be:
- A. “ECT produces a change in brain chemistry that results in improved mood.
- B. “ECT provides you with external punishment so you can stop punishing yourself.”
- C. “ECT interrupts brain impulses that are causing hallucinations and delusions.”
- D. ECT shocks the brain into re-establishing normal electrical patterns.”
Correct Answer: A
Rationale: Step 1: Electroconvulsive therapy (ECT) is a treatment for severe depression and other mental health disorders.
Step 2: Current biological theory suggests that ECT produces changes in brain chemistry, specifically neurotransmitters, leading to improved mood.
Step 3: The correct answer (A) aligns with this theory by explaining how ECT impacts brain chemistry to alleviate symptoms.
Step 4: Answer B is incorrect as ECT is not used as punishment but as a therapeutic intervention.
Step 5: Answer C is incorrect as ECT is not primarily used to interrupt brain impulses causing hallucinations and delusions.
Step 6: Answer D is incorrect as ECT does not shock the brain into re-establishing normal electrical patterns but rather affects neurotransmitter levels.
The parents of an 8-year-old are attempting to help their child comprehend new information. Which intervention suggested by the nurse shows an understanding of the cognitive development theory for this age group?
- A. The use of drawing and illustrations
- B. Comparing the child’s experiences to the new material
- C. Encouraging the child to talk about this new information
- D. Asking the child to give a reason for how they feel about new information
Correct Answer: B
Rationale: The correct answer is B: Comparing the child’s experiences to the new material. At the age of 8, children are in the concrete operational stage according to Piaget's cognitive development theory. This stage is characterized by the ability to think logically about concrete events and understand the concept of conservation. By comparing the child's experiences to the new material, the parents are helping the child make connections between what they already know and the new information, which facilitates understanding. Drawing and illustrations (choice A) are helpful for visual learners but may not necessarily tap into the child's cognitive development stage. Encouraging the child to talk about new information (choice C) is beneficial for communication skills but may not directly address cognitive development. Asking the child to give a reason for how they feel about new information (choice D) focuses more on emotions rather than cognitive understanding.