Nokea
A psychotic patient is delusional and has auditory hallucinations. The best statement to make when approaching the patient with an oral electronic thermometer would be:
- A. I need your vital signs. Put this in your mouth. This will not hurt.'
- B. I hope I can count on you to hold still while I take your temperature.'
- C. Please sit here while I take your temperature. I'll put the thermometer under your tongue for a few seconds.'
- D. This probe is only a thermometer that will tell us whether you have a fever. It will be all over in just a few seconds.'
Correct Answer: C
Rationale: The correct answer is C because it uses clear, simple language to explain the procedure to the patient. It acknowledges the patient's delusions by asking them to sit and calmly states the thermometer will be placed under their tongue. This approach is likely to minimize the patient's anxiety and increase cooperation.
Option A is incorrect as it may cause the patient to feel apprehensive due to the mention of "hurt." Option B is incorrect because it does not provide specific instructions about the procedure, which may lead to confusion for the patient. Option D is incorrect as it does not address the patient's delusions or provide clear instructions, potentially leading to increased resistance from the patient.
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A woman with Alzheimer's disease has significant apraxia and poor hygiene. Which intervention would be most appropriate for ensuring that the patient completes a shower?
- A. Remind her of the need for a shower and where the shower is, and repeat this every 30 minutes until the shower is completed.
- B. Discuss with her the importance of showers as part of daily self-care, and elicit and resolve any obstacles to the patient's showering.
- C. Walk her to the shower, and provide occasional reminders of what she should do next if she seems to be unsure or begins to repeat previous actions.
- D. Walk her to the shower, assist her to undress, start the water, supply the soap and washcloth, and instruct her to rub her face with the washcloth.
Correct Answer: D
Rationale: The correct answer is D because it provides the most direct and hands-on assistance to ensure completion of the shower. By walking her to the shower, assisting with undressing, starting the water, and providing necessary supplies and instructions, the patient is guided through each step of the showering process. This approach is essential for someone with significant apraxia and poor hygiene due to Alzheimer's disease.
Choice A is incorrect because simply reminding the patient every 30 minutes may not address the physical assistance needed for shower completion. Choice B is also incorrect as discussing the importance of showers may not be enough to overcome the challenges of apraxia and poor hygiene. Choice C is not as effective as choice D as occasional reminders may not provide the comprehensive assistance required for the patient to successfully complete the shower.
The nurse is planning care for a battered woman who has mentioned, 'Someday I'll have to leave him.' Which outcome should the nurse include in the plan of care for this client?
- A. Client will leave husband for a safe environment within 3 weeks
- B. Client will state that she feels more relaxed after consultation with nurse
- C. Client will state that she feels strong enough to return to the situation
- D. Client will verbalize awareness of the dangerousness of her situation
Correct Answer: D
Rationale: The correct answer is D: Client will verbalize awareness of the dangerousness of her situation. This outcome is crucial as it indicates the client's understanding of the risks involved in her current situation. By verbalizing awareness, the client is acknowledging the potential harm and taking a significant step towards recognizing the need for change. This outcome lays the foundation for further interventions and support.
Choice A is incorrect because setting a specific timeline for leaving may not be feasible or safe for the client. Choice B is incorrect as feeling relaxed does not necessarily address the underlying issue of abuse. Choice C is incorrect as feeling strong does not necessarily equate to recognizing the dangers of the situation. The focus should be on increasing awareness and empowering the client to make informed decisions.
The nurse is answering questions from a client and his family regarding a recent diagnosis of Alzheimer's disease. The client asks how effective medication is in treating the disease. What is the nurse's best response?
- A. There is no cure or treatment for Alzheimer's disease.'
- B. Medications have shown little improvement in symptoms.'
- C. Medications for the disease have been found to improve thinking abilities, behavior, and daily functioning in some clients.'
- D. Alternative therapies, such as co-enzyme Q-10 and Ginkgo biloba, are more effective than any of the prescription medications used to treat the symptoms.'
Correct Answer: C
Rationale: The correct answer is C because medications for Alzheimer's disease, such as cholinesterase inhibitors and memantine, have been found to improve thinking abilities, behavior, and daily functioning in some clients. These medications can help manage symptoms and slow down the progression of the disease. Option A is incorrect because while there is no cure for Alzheimer's disease, there are treatments available. Option B is incorrect as medications have shown some efficacy in managing symptoms. Option D is incorrect as there is limited scientific evidence to support the effectiveness of alternative therapies compared to prescription medications for Alzheimer's disease.
How does peer interaction influence mental development?
- A. Increases stress
- B. Enhances problem-solving
- C. Limits creativity
- D. Reduces attention span
Correct Answer: B
Rationale: Peer interaction enhances problem-solving (B) by encouraging collaboration and critical thinking, a key aspect of mental development. It doesn't inherently increase stress (A), limit creativity (C), or reduce attention (D).
Which intervention is appropriate for a patient who has anorexia nervosa and is resisting weight gain?
- A. Assist the patient to identify triggers to binge eating.
- B. Provide remedial consequences for weight loss.
- C. Assess for signs of impulsive eating.
- D. Explore needs for health teaching.
Correct Answer: A
Rationale: The correct answer is A because assisting the patient to identify triggers to binge eating is crucial in addressing the resistance to weight gain in anorexia nervosa. By understanding the triggers, the patient can work on overcoming them and develop healthier eating habits. Option B is incorrect as providing remedial consequences for weight loss may exacerbate the issue. Option C is incorrect as impulsive eating is not the main concern in anorexia nervosa. Option D is incorrect as exploring needs for health teaching does not directly address the resistance to weight gain in anorexia nervosa.