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A patient with antisocial personality disorder tells Nurse A, 'You're a much better nurse than Nurse B said you were.' The patient tells Nurse B, 'Nurse A's upset with you for some reason.' To Nurse C the patient states, 'You'd like to think you're perfect, but I've seen three of your mistakes this morning.' Which nursing intervention would be most helpful for addressing this behavior?
- A. Hold a weekly staff meeting to discuss feelings and conflicts related to such behavior.
- B. Confront the patient and advise her that if she continues this, she will lose privileges.
- C. Get all staff to agree that any and all inappropriate behavior will simply be ignored.
- D. Evaluate the patient for a medication increase or transfer to a long-term facility.
Correct Answer: A
Rationale: The correct answer is A: Hold a weekly staff meeting to discuss feelings and conflicts related to such behavior. This intervention promotes open communication among staff members to address and understand the patient's behavior. It allows for collaboration in managing challenging situations and ensures consistency in approach. Confronting the patient (B) may escalate the behavior and damage the therapeutic relationship. Ignoring inappropriate behavior (C) does not address the underlying issues and may lead to staff frustration. Evaluating for medication increase or transfer (D) should be considered only after non-pharmacological interventions have been exhausted.
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A patient is diagnosed with anorexia nervosa. A nurse who is assessing for co-morbid psychiatric disorders should begin by looking for signs of which common, concurrent diagnosis?
- A. Phobias.
- B. Depression.
- C. Schizophrenia.
- D. Personality disorder.
Correct Answer: B
Rationale: The correct answer is B: Depression. Anorexia nervosa commonly co-occurs with depression due to shared risk factors and biological mechanisms. Depression is often a primary trigger or consequence of anorexia nervosa, making it a crucial diagnosis to assess for. Phobias (choice A) may be present but are less commonly associated with anorexia nervosa. Schizophrenia (choice C) and personality disorders (choice D) are less likely to co-occur with anorexia nervosa compared to depression. Identifying and addressing depression in a patient with anorexia nervosa is essential for comprehensive treatment and improved outcomes.
A client in her early teens who is being treated for irritable bowel syndrome has just disclosed that she has been feeling anxious. For what other condition should the nurse assess this client?
- A. Anxiety.
- B. Depression.
- C. Eating disorder.
- D. None of the above.
Correct Answer: A
Rationale: Step 1: The client disclosed feeling anxious.
Step 2: Anxiety is a common comorbidity with irritable bowel syndrome.
Step 3: Assessing for anxiety allows for holistic treatment.
Step 4: Anxiety can impact the client's physical health.
Step 5: Therefore, assessing for anxiety is crucial.
Summary:
B: Depression - While depression is important, the client disclosed anxiety.
C: Eating disorder - Not directly related to the client's disclosure.
D: None of the above - Incorrect, as assessing for anxiety is necessary.
A 17-year-old client is admitted to the ED after being alternately hyperalert and difficult to arouse. His symptoms all started within the last few hours, during which time he became disoriented and confused. His behavior was agitated and restless, and his memory was impaired, especially for recent events. The client displayed some delusions and misinterpretations of his surroundings. The nurse knows she needs to assess the client further for:
- A. Dementia
- B. Depression
- C. Delirium
- D. Amnesia
Correct Answer: C
Rationale: The correct answer is C: Delirium. Delirium is characterized by acute and fluctuating changes in cognition, attention, and awareness. The client's sudden onset of symptoms, including disorientation, confusion, agitation, restlessness, impaired memory, delusions, and misinterpretations of surroundings, align with the hallmark features of delirium. The nurse needs to further assess the client for delirium to determine the underlying cause and provide appropriate interventions promptly.
Incorrect choices:
A: Dementia - Dementia is a chronic, progressive condition characterized by gradual cognitive decline. The client's acute onset of symptoms is not consistent with dementia.
B: Depression - Depression typically presents with persistent feelings of sadness, hopelessness, and loss of interest, which are different from the acute and fluctuating cognitive changes seen in delirium.
D: Amnesia - Amnesia refers to memory loss, which is only one aspect of the client's presentation. Delirium involves a broader range of cognitive
Which would be the best initial approach for a nurse to select when managing the care of an individual with two children who works full-time and has been abused by a partner?
- A. Teach the individual how to avoid provoking the abuser.
- B. Assist the individual in filing a police report describing the abuse.
- C. Help the individual to identify needs in order to best obtain support.
- D. Facilitate the individual's move into a safe house located near the current workplace.
Correct Answer: C
Rationale: The correct answer is C: Help the individual to identify needs in order to best obtain support. This is the best initial approach because it focuses on understanding the individual's specific needs and circumstances before taking any further action. By identifying needs, the nurse can create a tailored plan to provide appropriate support and resources.
Option A is incorrect because teaching the individual to avoid provoking the abuser places the responsibility on the victim rather than addressing the root cause of the abuse. Option B, filing a police report, may not be the best initial step as it may not take into consideration the individual's safety concerns or emotional well-being. Option D, moving the individual to a safe house, may not be feasible or desired by the individual without first understanding their needs and preferences.
An elderly patient must be physically restrained. Who is responsible for the patient's safety?
- A. The nurse assigned to care for the patient
- B. Unlicensed assistive personnel who apply the restraint
- C. Family member who agrees to application of the restraint
- D. Health care provider who prescribed application of restraint
Correct Answer: A
Rationale: The correct answer is A: The nurse assigned to care for the patient. The nurse is responsible for the patient's safety because they are the primary caregiver and have the training and knowledge to ensure proper application of restraints, monitor the patient's condition, and respond to any potential complications. Unlicensed assistive personnel (choice B) may apply restraints under the nurse's supervision but do not have the same level of training or accountability. Family members (choice C) and healthcare providers (choice D) may be involved in the decision-making process, but ultimate responsibility for patient safety lies with the nurse who directly cares for the patient.