Nokea
A patient with Alzheimer's disease has been determined to have a dressing/grooming self-care deficit. Which intervention(s) would be appropriate for this nursing diagnosis? Select all that apply.
- A. Replace personal clothing with gym clothes that all match each other.
- B. Label the patient's clothing with his name and name of the item.
- C. Provide clothing with elastic waistbands and hook-and-loop closures.
- D. None of the above.
Correct Answer: A
Rationale: Rationale: Option A is correct because replacing personal clothing with matching gym clothes simplifies dressing, reducing confusion for a patient with Alzheimer's. This intervention promotes independence and minimizes frustration. Labeling clothing (Option B) may help in identifying items but does not address the deficit. Clothing with elastic waistbands and closures (Option C) may be helpful but does not directly address the deficit. "None of the above" (Option D) is incorrect as Option A is an appropriate intervention.
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A 79-year-old white male tells a nurse, 'I have felt very sad lately. I do not have much to live for. My family and friends are all dead, and my own health is failing.' The nurse should analyze this comment as
- A. normal pessimism of the elderly.
- B. evidence of risks for suicide.
- C. a call for sympathy.
- D. normal grieving.
Correct Answer: B
Rationale: The correct answer is B: evidence of risks for suicide. The elderly man's statement indicates feelings of hopelessness, loneliness, and lack of purpose, which are common risk factors for suicide in older adults. The nurse should assess further for suicidal ideation and intervene accordingly.
Choice A is incorrect because the statement goes beyond normal pessimism by expressing thoughts of not having much to live for. Choice C is incorrect as the statement is more indicative of distress rather than a mere call for sympathy. Choice D is incorrect as normal grieving typically involves processing emotions related to a specific loss, whereas the man's statement reflects a broader sense of despair.
A student transfers from a hometown college to a university 200 miles away after breaking up with her boyfriend of 2 years. She was slow to make friends at the university. The history shows a close relationship with her mother and sister. She began eating large quantities when she felt sad, and then she induced vomiting. When the student's schoolwork declined, she sought help from the university health clinic. During the initial interview, what priority issue should the nurse address?
- A. Losses
- B. Sleep patterns
- C. School activities
- D. Menstrual flow
Correct Answer: A
Rationale: The correct answer is A: Losses. The priority issue the nurse should address is the student's recent breakup and difficulty making friends, which are significant losses impacting her emotional well-being. By addressing these losses, the nurse can help the student process her emotions and develop coping strategies.
B: Sleep patterns may be affected by the student's emotional distress, but it is a secondary concern compared to addressing the underlying losses.
C: School activities are important, but the root cause of the student's decline in schoolwork is likely related to her emotional state following the breakup.
D: Menstrual flow is not the priority issue at this time as it is not directly related to the student's emotional struggles and academic decline.
A patient living independently had command hallucinations to shout warnings to neighbors. After a short hospitalization, the patient was prohibited from returning to the apartment. The landlord said, 'You cause too much trouble.' What problem is the patient experiencing?
- A. Grief
- B. Stigma
- C. Homelessness
- D. Nonadherence
Correct Answer: B
Rationale: The inability to obtain shelter because of negative attitudes about mental illness is an example of stigma. Stigma is defined as damage to reputation, shame, and ridicule society places on mental illness. Data are not present to identify grief as a patient problem. Data do not suggest that the patient is actually homeless.
Which of the following best describes a social gambler
- A. Someone who gambles for the heightened thrill and needs higher bets to achieve the same feeling
- B. Gambles for fun during New Year gatherings
- C. Believes gambling is a way to make money, similar to financial investment
- D. Steals money to feed the gambling habit
Correct Answer: B
Rationale: A social gambler engages in gambling recreationally, such as during social events like New Year gatherings, without dependency.
A patient with schizophrenia is admitted to the psychiatric unit in an acutely disturbed, violent state. He is given several doses of haloperidol (Haldol) and becomes calm and approachable. During rounds the nurse notices the patient has his head rotated to one side in a stiffly fixed position. His lower jaw is thrust forward and he appears severely anxious. The patient has ______, and the nurse should ______.
- A. a dystonic reaction"¦administer PRN IM benztropine (Cogentin)
- B. tardive dyskinesia"¦seek a change in the drug or its dosage
- C. waxy flexibility"¦continue treatment with antipsychotic drugs
- D. akathisia"¦administer PRN diphenhydramine (Benadryl) PO
Correct Answer: A
Rationale: The correct answer is A: a dystonic reaction"¦administer PRN IM benztropine (Cogentin).
1. Dystonic reaction is characterized by involuntary muscle contractions, causing abnormal posture or movements.
2. The patient's symptoms of head rotation, jaw thrust, and severe anxiety align with dystonic reaction.
3. Benztropine is an anticholinergic medication used to treat dystonic reactions by blocking acetylcholine in the brain.
4. Administering benztropine promptly can alleviate the symptoms and prevent complications.
Other choices are incorrect:
B: Tardive dyskinesia develops with long-term antipsychotic use, presenting as repetitive, involuntary movements. Seeking a change in drug or dosage is not appropriate for acute dystonic reaction.
C: Waxy flexibility is a symptom of catatonia, not related to the patient's presentation of dystonic reaction.
D: Akathisia is restlessness and agitation often caused by