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A young, newly married adult says, 'My spouse never lets me out of sight. I'm not allowed to do anything on my own, and I'm constantly accused of cheating.' Which nursing communication is most therapeutic for this patient?
- A. Have you discussed the behavior with your spouse?'
- B. How does your spouse's behavior make you feel?'
- C. Are there other examples of controlling behaviors on your spouse's part?'
- D. Do you feel that your spouse has anything to be upset or suspicious about?'
Correct Answer: B
Rationale: The correct answer is B: "How does your spouse's behavior make you feel?" This question focuses on the patient's emotions, allowing them to express their feelings and validating their experiences. It shows empathy and encourages the patient to explore and understand their own emotional responses to the situation.
Choice A focuses on addressing the behavior directly without acknowledging the patient's emotions. Choice C asks for more examples of controlling behavior, which may feel judgmental. Choice D suggests that the spouse's behavior is justified, which can further invalidate the patient's feelings. Overall, choice B is the most therapeutic as it promotes emotional exploration and support.
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An acutely psychotic individual diagnosed with schizophreniaform disorder at admission is immediately placed on daily doses of risperidone. A hospitalization of 8 days' duration has been authorized by the HMO. By what hospital day would the nurse expect to note that client was demonstrating beginning trust in the nurse and reduction in hallucinations and delusions?
- A. Day of admission
- B. Day 3 of hospitalization
- C. Day 5 of hospitalization
- D. Day 7 of hospitalization
Correct Answer: B
Rationale: The correct answer is B: Day 3 of hospitalization. At this point, the risperidone medication would have had sufficient time to begin exerting its therapeutic effects on the individual's symptoms of hallucinations and delusions. It typically takes a few days for antipsychotic medications like risperidone to reach therapeutic levels in the body and start alleviating psychotic symptoms. By day 3, the individual may start to demonstrate improved trust in the nurse due to the reduction in distressing symptoms.
Incorrect options:
A: Day of admission - It is unlikely to see significant improvement in symptoms and trust on the same day of admission.
C: Day 5 of hospitalization - By this time, the medication would have likely already started showing some effects, and the individual would have had some time to build trust with the nurse.
D: Day 7 of hospitalization - Waiting until day 7 might be too late to note beginning trust and significant reduction in symptoms, as the
Several children a day are seen in the emergency department for treatment of illnesses and injuries. The situation that would create a high index of suspicion of child abuse is a child who:
- A. Has repeated middle ear infections.
- B. Complains of abdominal cramps and upset stomach.
- C. Has perineal bruises and urinary tract infections.
- D. Displays reduced functioning at school.
Correct Answer: C
Rationale: The correct answer is C because perineal bruises and urinary tract infections are physical signs that are highly suspicious for child abuse, particularly sexual abuse. Perineal bruises are not commonly seen in children due to accidental injuries, and urinary tract infections in young children are rare and may indicate sexual abuse. Repeated middle ear infections (choice A) and complaints of abdominal cramps and upset stomach (choice B) are common childhood illnesses that do not necessarily indicate child abuse. Displaying reduced functioning at school (choice D) may suggest various issues such as learning disabilities or emotional distress, but is not specific to child abuse.
Which of the following statements by a patient with anorexia nervosa indicates a need for further education?
- A. I want to gain weight, but only if I can stay under 120 pounds.
- B. I understand that my body weight is dangerously low.
- C. I know that food is the enemy and I need to avoid it at all costs.
- D. I am willing to work with my healthcare team to improve my nutrition.
Correct Answer: C
Rationale: The correct answer is C because it indicates a misunderstanding of anorexia nervosa. Patients with anorexia often see food as the enemy, which is a distorted perception. Understanding that food is necessary for nourishment and health is crucial in recovery. Choice A shows an unhealthy weight goal, choice B shows awareness of low weight, and choice D shows willingness to work with the healthcare team, all of which are positive signs.
A patient experiencing delirium secondary to corticosteroid toxicity is manifesting paranoid thinking and noisy, assaultive behavior. The patient is currently pacing the hall and shouting. A nurse has placed a call to the physician and is anticipating the following order:
- A. the use of supervised restraints.
- B. a loading dose of phenytoin.
- C. a small dose of prednisone.
- D. an IV dose of thiamine.
Correct Answer: A
Rationale: The correct answer is A: the use of supervised restraints. In this situation, the patient is displaying agitated and assaultive behavior, posing a risk to themselves and others. Supervised restraints are necessary to ensure the safety of the patient and healthcare providers until the effects of corticosteroid toxicity subside. Restraints should only be used as a last resort when other interventions have failed.
Choice B: A loading dose of phenytoin is incorrect because phenytoin is not indicated for managing delirium secondary to corticosteroid toxicity.
Choice C: A small dose of prednisone is incorrect because adding more corticosteroids would exacerbate the toxicity and worsen the delirium.
Choice D: An IV dose of thiamine is incorrect as thiamine is used to treat thiamine deficiency, not corticosteroid toxicity-induced delirium.
Children should undergo further evaluation when their weight is % above their height.
- A. 10
- B. 15
- C. 20
- D. 25
Correct Answer: C
Rationale: The correct answer is C (20%). This is because a weight that is 20% above a child's height can indicate potential health issues such as obesity. Excess weight can lead to various health problems in children. Choices A, B, and D are incorrect as they represent lower percentages, which may not be as concerning in terms of potential health risks. It is important to consider a higher percentage threshold for further evaluation to ensure early detection and intervention for any weight-related issues.