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About an hour after the patient has ECT, he complains of having a headache. The nurse should:
- A. Notify the physician stat.
- B. Administer an as needed (prn) dose of acetaminophen.
- C. Take the patient through a progressive relaxation sequence.
- D. Advise going to activities to expend energy and relieve tension.
Correct Answer: B
Rationale: The correct answer is B: Administer an as needed (prn) dose of acetaminophen. After ECT, it is common for patients to experience headaches as a side effect. Administering acetaminophen will help alleviate the headache and provide relief for the patient. It is important to address the patient's discomfort promptly and effectively.
Choice A is incorrect because headaches after ECT are a common side effect and do not typically require immediate physician notification. Choice C is incorrect as progressive relaxation may not address the immediate headache symptoms. Choice D is also incorrect as physical activities may exacerbate the headache rather than provide relief. Administering acetaminophen is the most appropriate and efficient intervention in this situation.
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A 70-year-old male has the nursing diagnosis of situational low self-esteem related to forced retirement. Using Maslow’s hierarchy, the nurse is confident the patient is meeting self-worth outcomes when the patient:
- A. Moves to a secure apartment building
- B. Exercises regularly with friends at the gym
- C. Attends his grandchildren’s school functions
- D. Volunteers at the local homeless shelter weekly
Correct Answer: D
Rationale: The correct answer is D because volunteering at the local homeless shelter fulfills the self-actualization need in Maslow's hierarchy. By helping others and contributing to the community, the patient gains a sense of purpose and fulfillment, boosting self-esteem.
A: Moving to a secure apartment building addresses safety needs, not self-esteem.
B: Exercising with friends promotes social belonging but does not directly address self-esteem.
C: Attending grandchildren's functions fosters social connections, but it may not directly impact self-esteem like volunteering does.
The nurse is determining whether the patient’s needs could be best met in a task or a process group. The decision is based on the understanding that a task group focuses on:
- A. The “here and now”
- B. Communication styles
- C. Relations among the members
Correct Answer: A
Rationale: The correct answer is A: The "here and now." In a task group, the focus is on addressing specific goals, tasks, and problem-solving in the present moment. This approach helps members work together efficiently to achieve objectives. Communication styles (B) are more relevant in a group focused on improving communication skills. Relations among the members (C) are typically emphasized in a process group, where the focus is on interpersonal dynamics and relationships. Choice D is incomplete and does not align with the purpose of a task group.
A grief support group is held at the local community center to assist persons who are dealing with issues of loss. Which remark by one of the members would the nurse interpret as indicating unresolved feelings of guilt?
- A. “I know that my husband had a good life.”
- B. “It seems I miss my son more as time goes on.”
- C. “I am still wishing I had gotten help to him sooner.”
- D. "The holidays are always so hard for me now."
Correct Answer: C
Rationale: The correct answer is C because the statement indicates feelings of guilt about not getting help sooner, suggesting the member may blame themselves for the loss. This remark reflects a sense of responsibility and regret, common in unresolved guilt. Choice A expresses acceptance, B reflects natural grief progression, and D highlights difficulty during specific times, not necessarily linked to guilt. By analyzing the content of each statement, the nurse can identify cues related to unresolved feelings of guilt.
Which initial short-term outcome would be appropriate for a patient admitted with delusional thoughts?
- A. Accept that delusion is illogical.
- B. Distinguish external boundaries.
- C. Explain the basis for the delusions.
- D. Engage in reality-oriented conversation.
Correct Answer: D
Rationale: The correct answer is D, engage in reality-oriented conversation. This is appropriate because it helps the patient ground themselves in reality and potentially reduce the intensity of their delusions. By discussing real-life events and situations, the patient is encouraged to recognize the disparity between their delusional thoughts and actual reality. Choice A is incorrect as simply accepting the delusion as illogical does not actively address the patient's condition. Choice B, distinguishing external boundaries, is not as effective in directly challenging the delusional thoughts. Choice C, explaining the basis for the delusions, may not be helpful initially as the patient may not be receptive to logical explanations due to their distorted thinking.
Which statement best explains how a mother of several children should prepare to help them cope with the loss of a dear aunt?
- A. Each child will grieve in a unique way and on their own timetable
- B. Children are resilient and simply need love as they grieve.
- C. People regardless of age or gender experience stages of grief.
- D. Extreme reactions are more commonly observed in the young griever
Correct Answer: A
Rationale: The correct answer is A because each child will indeed grieve in a unique way and on their own timetable. This approach recognizes the individuality of each child's emotions and coping mechanisms. By understanding and respecting their differences, the mother can provide tailored support and comfort. Option B oversimplifies the grieving process and ignores the complexity of individual responses. Option C generalizes the stages of grief for all people and does not account for variations in how children may process loss. Option D incorrectly suggests that extreme reactions are more common in young children, which is not necessarily true as grief responses can vary widely among children.