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A patient with severe dementia can no longer recognize her only daughter and becomes anxious and agitated when the daughter attempts to reorient her. An alternative the nurse could suggest to the daughter is to:
- A. Wear a large name tag.
- B. Visit her mother less often.
- C. Talk about experiences they've shared.
- D. None of the above.
Correct Answer: C
Rationale: The correct answer is C: Talk about experiences they've shared. This option is the most appropriate because reminiscing about past shared experiences can help trigger memories and emotions in the patient with dementia, potentially reducing anxiety and agitation. It can provide comfort and a sense of familiarity to the patient. Wearing a large name tag (option A) may not address the core issue of memory loss. Visiting less often (option B) could lead to further feelings of isolation and confusion for the patient. Option D, None of the above, is incorrect as option C provides a constructive and person-centered approach to improving the interaction between the patient and her daughter.
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A patient's body is covered by fine, downy hair. The patient weighs 70 pounds and is 5 feet 4 inches tall. Which term should be documented?
- A. Amenorrhea
- B. Alopecia
- C. Lanugo
- D. Stupor
Correct Answer: C
Rationale: The correct term to be documented is C: Lanugo. Lanugo is fine, downy hair that can cover a patient's body, often seen in newborns or individuals with certain medical conditions. In this case, the presence of lanugo indicates a potential underlying issue. Amenorrhea (A) refers to the absence of menstruation, not related to the hair. Alopecia (B) is hair loss, the opposite of lanugo. Stupor (D) is a state of reduced consciousness, not related to the hair condition described. Therefore, choice C is the correct answer as it directly matches the description given in the question.
A nurse is caring for a patient with bulimia nervosa who has not eaten for 24 hours. The nurse should first:
- A. Encourage the patient to eat a full meal immediately.
- B. Assess the patient's vital signs and hydration status.
- C. Provide the patient with a menu to select food for the next meal.
- D. Contact the physician for a medication prescription.
Correct Answer: B
Rationale: The correct answer is B because assessing vital signs and hydration status is crucial in identifying potential complications from prolonged fasting in a patient with bulimia nervosa. This step helps determine the patient's immediate needs for intervention and guides further care planning. Encouraging the patient to eat a full meal immediately (Choice A) may lead to refeeding syndrome due to electrolyte imbalances. Providing a menu for the next meal (Choice C) is not the priority when the patient has not eaten for 24 hours. Contacting the physician for a medication prescription (Choice D) is not necessary at this point without first assessing the patient's current physical status.
For those family members who desire to care at home for loved ones who have been given a diagnosis of Alzheimer's disease, it is important for the nurse to ensure that the family is aware of which caregiver skills and responsibilities will be necessary. What is one of the responsibilities of the caregiver during the middle stage of the disease?
- A. Helping the loved one with memory and communication problems.
- B. Providing a stable, routine environment.
- C. Providing complete assistance with physical care.
- D. None of the above.
Correct Answer: A
Rationale: Rationale:
1. During the middle stage of Alzheimer's disease, individuals often experience memory and communication problems.
2. Caregivers need to assist with memory tasks and facilitate effective communication.
3. Helping the loved one with memory and communication problems is crucial for their well-being and quality of life.
4. This responsibility helps maintain a sense of connection and understanding between the caregiver and the individual with Alzheimer's.
Summary:
- Option A is correct as it aligns with the specific needs of individuals in the middle stage of Alzheimer's.
- Option B is incorrect as providing a stable, routine environment is more relevant in the early stages.
- Option C is incorrect as complete assistance with physical care is more common in the later stages.
- Option D is incorrect as caregiver responsibilities are essential in all stages of the disease.
The nurse is interviewing a client who presents with a dislocated shoulder. She demonstrates signs of anxiety and poor eye contact and turns to her partner for answers, allowing him to answer for her. Bruises on her breast and upper arm are visible. The nurse asks the partner to go to the admitting office to give insurance information. While the partner is out of the room, which question is most important to ask?
- A. Have you been with your partner long?'
- B. Have you ever been physically or emotionally hurt by someone?'
- C. Are you an abused woman?'
- D. Shall I notify the police that you would like to press charges?'
Correct Answer: B
Rationale: The correct answer is B: "Have you ever been physically or emotionally hurt by someone?" This question is important as it directly addresses the potential abuse the client may be experiencing. It allows the nurse to assess for any history of abuse, which could be contributing to the client's anxiety and behavior. It also opens up an opportunity for the client to disclose any abuse they may be facing.
Choice A is incorrect because the length of the relationship with the partner is not as crucial as addressing the potential abuse. Choice C is also incorrect because it is too direct and may not encourage the client to open up about their experiences. Choice D is incorrect as it assumes the client wants to press charges without first assessing the situation and the client's wishes.
An 11-year-old boy stays home from school to care for his siblings while his mother works, because the family cannot afford a babysitter. During the community mental health nurse's visit, he reveals that he thinks his father does not like him because he calls him 'stupid' all the time. He states he is too dumb to learn much and has no friends at school because he does not deserve them. Which nursing diagnosis should be the priority for the child?
- A. Helplessness
- B. Knowledge deficit
- C. Ineffective coping
- D. Chronic low self-esteem
Correct Answer: D
Rationale: The correct answer is D: Chronic low self-esteem. This diagnosis is appropriate because the child displays a negative self-concept, feeling unworthy, lacking confidence, and believing he is "stupid" and undeserving of friends. This impacts his self-worth and psychological well-being. Chronic low self-esteem is the priority to address as it affects various aspects of his life.
Choice A: Helplessness may seem relevant due to the family situation, but the child's core issue is more about self-worth than feeling helpless in his situation.
Choice B: Knowledge deficit is not the priority as the child's issue lies more in his emotional well-being rather than lack of information.
Choice C: Ineffective coping might be a concern, but the root of his struggles is his self-esteem, making chronic low self-esteem the primary focus.