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A patient tells a nurse, 'The others won't give me my pain meds early, but you are more understanding, you know what it's like to be in pain, and you don't want to see your patients suffer. Could you find a way to get me my pill now? I won't tell anyone.' Which response by the nurse would be most therapeutic?
- A. I'm not comfortable doing that,' then ignore subsequent requests for early meds.
- B. I'll have to check with your doctor about that; I will get back to you after I do.'
- C. It would be unsafe to give the medicine early; none of us will do that.'
- D. I understand that you have pain, but giving medicine too soon would not be safe.'
Correct Answer: D
Rationale: Step 1: Acknowledge the patient's pain and show understanding.
Step 2: Emphasize the importance of safety in medication administration.
Step 3: Set clear boundaries by explaining why giving medicine too soon is unsafe.
Step 4: Reiterate empathy for the patient's pain while prioritizing safety.
Summary: Answer D is correct as it acknowledges the patient's pain, emphasizes safety, sets clear boundaries, and maintains empathy. Other choices either ignore the patient's request, defer responsibility, or solely focus on safety without empathy.
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Which situation would be most likely to serve as a trigger to a catastrophic reaction in a client with stage 2 Alzheimer's disease?
- A. Participating in singing 'Happy Birthday' to another client at dinner
- B. Being scolded by an aide for spilling a glass of milk
- C. Listening to Big Band music from the 1940s
- D. Eating cupcakes in the activities room
Correct Answer: B
Rationale: The correct answer is B because being scolded for spilling milk can trigger feelings of shame, embarrassment, and confusion in a person with Alzheimer's stage 2. This negative interaction can lead to heightened agitation, aggression, or emotional distress due to the client's impaired ability to process and regulate emotions. In contrast, choices A, C, and D involve positive or neutral activities that are less likely to evoke such strong negative emotions or reactions in someone with Alzheimer's disease.
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: Anticholinergic effects are cumulative in older adults and often have adverse consequences related to accidents and injuries (A), making it the highest priority. The other issues (B, C, D) may be relevant but are less critical.
A patient diagnosed with dementia associated with excessive alcohol use tells a nurse, "Last week I had to take my baby to the hospital for major surgery. That's why I've been so nervous and needed to come here."Â The nurse is aware that the patient has never parented any children. The symptom described can be assessed as:
- A. akathisia.
- B. confabulation.
- C. intellectualization.
- D. magical thinking.
Correct Answer: B
Rationale: The correct answer is B: confabulation. Confabulation is the production of fabricated or distorted memories without the conscious intention to deceive. In this case, the patient is creating a false memory about having a baby and needing to take it to the hospital, which is not based on reality. Akathisia (A) is a movement disorder associated with restlessness, not memory distortion. Intellectualization (C) is a defense mechanism involving excessive focus on facts to avoid uncomfortable emotions, not memory fabrication. Magical thinking (D) involves believing that one's thoughts can influence events, not creating false memories.
A patient is referred to the visiting nurse agency due to cognitive impairment. Which functional problems is this patient most likely to exhibit?
- A. Inability to bathe and dress independently.
- B. Wandering in and away from his home.
- C. Lability of moods, from sociable to irritable.
- D. None of the above.
Correct Answer: A
Rationale: The correct answer is A: Inability to bathe and dress independently. Cognitive impairment can impact a person's ability to remember tasks and follow routines, resulting in difficulties with self-care activities like bathing and dressing. This is a common functional problem seen in patients with cognitive impairment.
Choice B (Wandering) is more indicative of behavioral symptoms like agitation and restlessness. Choice C (Mood lability) is related to emotional regulation and not directly related to functional problems caused by cognitive impairment. Choice D (None of the above) is incorrect as cognitive impairment often leads to difficulties with self-care tasks.
Major concerns of the elderly living alone in their home are: (Name 2)
- A. Safety
- B. Quality of life
- C. Support system
- D. Access to medical care
Correct Answer: C
Rationale: Support system (C) is another major concern for the elderly living alone, ensuring they have assistance when needed. The question asks for two concerns, with safety (A) as the first and support system as the second common issue.