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A patient with acute mania approaches the nurse, waves a newspaper, and says, "I want the phone right now. I need to call this store while their sale is going on. I need ten dresses and four pairs of shoes." Select the nurse's best intervention.
- A. Suggest the patient ask a friend do the shopping and bring purchases to the unit.
- B. Invite the patient to sit with the nurse and look at new fashion magazines.
- C. Tell the patient phone use is not allowed until self-control is improved.
- D. Ask whether the patient has enough money to pay for the purchases.
Correct Answer: C
Rationale: The correct answer is C because the patient's behavior is impulsive and reflects poor judgment, which are common symptoms of acute mania. By telling the patient that phone use is not allowed until self-control is improved, the nurse is setting a boundary to prevent further impulsive actions. This intervention prioritizes safety and helps maintain a therapeutic environment.
A: This option does not address the immediate need to manage the patient's impulsive behavior and may put the friend in a potentially risky situation.
B: Inviting the patient to look at fashion magazines does not address the impulsivity and may even reinforce the behavior.
D: Asking about the patient's financial situation is not the most appropriate intervention at this time.
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After a person was abducted and raped at gunpoint by an unknown assailant, which assessment finding best indicates the acute phase of the rape-trauma syndrome?
- A. Decreased motor activity
- B. Confusion and disbelief
- C. Flashbacks and dreams
- D. Fears and phobias
Correct Answer: B
Rationale: The correct answer is B: Confusion and disbelief. During the acute phase of rape-trauma syndrome, the victim may experience feelings of confusion and disbelief as they try to process the traumatic event. This initial reaction is a common response to such a severe and violating experience. The victim may struggle to comprehend what has happened to them, leading to feelings of shock and disbelief. This phase is characterized by emotional numbing, disorientation, and difficulty in making decisions.
Decreased motor activity (Choice A) is not specific to the acute phase of rape-trauma syndrome and can be a general response to trauma. Flashbacks and dreams (Choice C) are more commonly associated with the intrusion phase of the syndrome, which occurs after the acute phase. Fears and phobias (Choice D) may develop later in the reorganization phase of the syndrome as the victim tries to cope with the aftermath of the trauma.
A nurse planning a group to help batterers learn more effective ways to cope would teach participants that the key component in wife battering is:
- A. The need for the batterer to control
- B. Alcohol abuse by the batterer
- C. History of psychotic behavior
- D. Failure of the woman to assert herself
Correct Answer: A
Rationale: The correct answer is A: The need for the batterer to control. This is the key component in wife battering, as it is rooted in the batterer's desire to establish power and dominance over their partner. Teaching batterers more effective ways to cope involves addressing this underlying need for control.
Explanation of other choices:
B: Alcohol abuse by the batterer - While alcohol abuse may exacerbate violent behavior, it is not the primary cause of wife battering.
C: History of psychotic behavior - Psychotic behavior may contribute to violence, but it is not the key component in wife battering.
D: Failure of the woman to assert herself - Blaming the victim is not appropriate; the responsibility lies with the batterer's need for control.
Which theorist emphasized the role of social interaction in mental development?
- A. Piaget
- B. Vygotsky
- C. Erikson
- D. Freud
Correct Answer: B
Rationale: Vygotsky (B) emphasized social interaction and the Zone of Proximal Development in mental growth, unlike Piaget (A, cognitive stages), Erikson (C, psychosocial), or Freud (D, psychosexual).
Which goal has priority for a patient with anorexia nervosa undergoing nutritional stabilization?
- A. Schedules meals appropriately
- B. Eats 100% of each meal served
- C. Selects food items from a menu
- D. Prepares food under supervision
Correct Answer: B
Rationale: The correct answer is B because ensuring the patient eats 100% of each meal served is crucial for nutritional rehabilitation in anorexia nervosa. This goal helps the patient meet their caloric needs and address malnutrition. It is essential to monitor and support the patient in consuming all the food provided to promote weight restoration and overall health. The other options are less critical: A focuses on timing rather than full intake, C involves choice rather than completion, and D emphasizes supervision but not necessarily full consumption.
A patient with anorexia nervosa is at risk for refeeding syndrome. The nurse should be most concerned with:
- A. Hyperglycemia.
- B. Electrolyte imbalances, particularly hypophosphatemia.
- C. Increased hunger and overeating.
- D. Rapid weight gain and hypertension.
Correct Answer: B
Rationale: The correct answer is B: Electrolyte imbalances, particularly hypophosphatemia. Refeeding syndrome occurs when a malnourished individual receives nutrition too quickly, leading to shifts in electrolytes like phosphate, potassium, and magnesium. Hypophosphatemia is a key concern due to its potential to cause cardiac and respiratory failure. Hyperglycemia (A) may occur but is not the primary concern. Increased hunger and overeating (C) are common symptoms of anorexia nervosa but not directly related to refeeding syndrome. Rapid weight gain and hypertension (D) are potential consequences of refeeding but are not the immediate concern compared to electrolyte imbalances.