Nokea
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.
You may also like to solve these questions
Which nursing intervention supports the principles on which the cross-links theory of aging is based?
- A. Applying an elastin-sustaining moisturizer to an adult patient’s skin
- B. Assessing a patient’s family history for genetic diseases and disorders
- C. Questioning a patient about long-term exposure to environmental toxins
- D. Assisting an adult patient in selecting foods high in vitamins A, C, and E
Correct Answer: D
Rationale: The correct answer is D because selecting foods high in vitamins A, C, and E supports the principles of the cross-links theory of aging, which focuses on the accumulation of damage from oxidative stress. Vitamins A, C, and E are antioxidants that help combat oxidative stress and reduce the formation of cross-links in tissues. This intervention can potentially slow down the aging process by reducing cellular damage.
Choice A is incorrect because applying an elastin-sustaining moisturizer does not directly address the oxidative stress aspect of the cross-links theory of aging.
Choice B is incorrect as assessing family history for genetic diseases does not specifically target the mechanisms involved in the cross-links theory of aging.
Choice C is incorrect because questioning about exposure to environmental toxins may be important for overall health but is not directly related to the principles of the cross-links theory of aging.
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.
Discharge planning begins for an elderly patient hospitalized for 2 weeks diagnosed with major depression. The patient needs ongoing assessment and socialization opportunities as well as education about medication and relapse prevention. The patient lives with a daughter, who works during the week. Select the best referral for this patient.
- A. Behavioral health home care
- B. Partial hospitalization
- C. A skilled nursing facility
- D. A halfway house
Correct Answer: A
Rationale: The correct answer is A: Behavioral health home care. This option provides ongoing assessment, socialization opportunities, and education about medication and relapse prevention, which are all essential for the elderly patient with major depression. Additionally, it allows the patient to stay in their own home environment, promoting comfort and familiarity.
Option B: Partial hospitalization may not provide the ongoing support and socialization opportunities needed for the patient.
Option C: A skilled nursing facility may offer medical care but may not focus on mental health needs or socialization.
Option D: A halfway house is typically for individuals transitioning from addiction treatment and may not address the specific needs of an elderly patient with major depression.
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.
Which description is characteristic of an impulsive child?
- A. Running out into the street regardless of frequent instruction to look both ways first.
- B. Pacing and speaking in a very loud, disruptive voice
- C. Frequently talking about hearing voices telling him what to do
- D. Having a difficult time concentrating on reading since his attention is easily diverted
Correct Answer: A
Rationale: The correct answer is A. An impulsive child typically acts without thinking or considering consequences, such as running into the street without looking. This behavior is impulsive, risky, and disregards safety instructions. Choices B and C describe behaviors that are more indicative of other issues like hyperactivity or hallucinations. Choice D suggests difficulty concentrating, which is not directly related to impulsivity. In summary, the key characteristic of an impulsive child is acting quickly without considering potential dangers or instructions.