Nokea
A young woman had just learned of the accidental death of her husband. She begins to cry and states, “It’s not fair! How could he do this to me?” This remark is assessed as:
- A. An explosive episode
- B. An expression of anger
- C. Fear of making decisions alone
- D. A sign of despair.
Correct Answer: B
Rationale: The woman's statement, "It's not fair! How could he do this to me?" expresses a sense of anger and injustice over her husband's accidental death. She is questioning why this has happened to her, which suggests feelings of anger and frustration. This expression is not necessarily a plea for help or a manifestation of fear of making decisions alone, but it is a clear display of anger and a sense of unfairness in the situation.
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The community health nurse is visiting a patient diagnosed with dysfunctional grieving since the death of his wife and child over a year ago. Which actions should the nurse implement first?
- A. Promote interaction with others.
- B. Assess risk of self-directed violence.
- C. Facilitate expression of feelings related to the loss.
Correct Answer: B
Rationale: Assessing the risk of self-directed violence is the priority when dealing with a patient diagnosed with dysfunctional grieving. Individuals experiencing complicated grief may be at an increased risk for self-harm or suicidal ideation. By assessing the risk of self-directed violence first, the nurse can ensure the patient's safety and provide appropriate interventions if necessary. Once the risk is assessed and managed, the nurse can then proceed with other interventions such as promoting interaction with others and facilitating the expression of feelings related to the loss.
Which older adult patient’s medical conditions support the hypothesis upon which the immunologic theory of aging is based?
- A. Has, at age 64, been diagnosed with type 2 diabete
- B. Has been treated for multiple sclerosis since age 30.
- C. Is managing a 36-year history of chronic Graves’ disease.
- D. Has begun to experience symptoms of rheumatoid arthritis.
Correct Answer: B, C
Rationale: he immunologic theory of aging suggests that aging is associated with increased autoimmunity. Conditions like multiple sclerosis, rheumatoid arthritis, and Graves’ disease reflect immune dysfunction.
Which complaint is representative of anxiety in a 6-year-old child?
- A. I worry that my dad will get hurt at work.
- B. I get a stomach ache when it's my weekend at my dad's house.
- C. I can't sleep when I stay at Grandma's because I worry about my mom.
- D. I'm not going to sports camp because I don't like being away from my friends.
Correct Answer: B
Rationale: Children often express anxiety through physical complaints like stomachaches, especially in situations that cause distress or discomfort, such as visiting a noncustodial parent.
A new nurse asks the mentor, “How can I be sure I’m developing a therapeutic environment for my unit?” The mentor uses as a basis for the response the fact that a therapeutic milieu is characterized by:
- A. Rigid adherence to timelines and unit routine
- B. Relaxation of boundaries when doing so is accepted by all
- C. Working with a member to help improve their communication skill
- D. The focus of the staff is directed to the most critically disturbed patients
Correct Answer: D
Rationale: A therapeutic milieu is characterized by focusing on the needs and goals of the patients. By establishing specific patient-centered goals that are agreed upon mutually by the patient and the staff, it ensures that the care provided is individualized and tailored to the patient's needs. This approach fosters a collaborative and empowering environment where the patient feels heard and supported in their recovery journey. It also promotes a sense of ownership and accountability for both the patient and the staff in working towards these goals together. In contrast, rigid adherence to timelines and unit routine (option A) may not always take into account the unique needs of each patient, and relaxation of boundaries (option B) can potentially compromise the therapeutic process by blurring professional boundaries. Therefore, establishing patient-centered goals is a key component of creating a therapeutic environment on a nursing unit.
The physician has ordered atropine 5 mg intramuscularly (IM) for a patient to be administered 30 minutes prior to ECT. The rationale for use of this medication is that it reduces secretions and:
- A. Improves the scope of convulsive activity
- B. Reduces the need for recovery room staff
- C. Prevents incontinence of bladder and bowel
- D. Increases the patient's alertness post-procedure.
Correct Answer: A
Rationale: The rationale for using atropine 5 mg IM prior to ECT is to protect against vagal bradycardia, not to improve the scope of convulsive activity, reduce the need for recovery room staff, or prevent incontinence of bladder and bowel. Atropine is a muscarinic antagonist that blocks the effects of acetylcholine on muscarinic receptors, leading to an increase in heart rate and protection against bradycardia that can occur during ECT.