Nokea
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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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.
The patient states, "Everybody picks on me. They frobitz me." The patient’s communication exhibits:
- A. A neologism
- B. Loose associations
- C. Delusional thinking
- D. Circumstantial speech
Correct Answer: A
Rationale: The correct answer is A: A neologism. A neologism is a made-up word or phrase that only has meaning to the individual. In this case, "frobitz" is not a known word in the English language, indicating a neologism. This suggests possible language or thought disorder. B: Loose associations involve disconnected or tangential thoughts. C: Delusional thinking involves fixed false beliefs. D: Circumstantial speech includes excessive, irrelevant detail before reaching the main point.
During a grief-processing group, an elderly patient stated, “For the first time since my husband died, I’m having more good days than bad.” This statement suggests that the patient has:
- A. Reached the phase of reestablishment
- B. Determined she is ready to terminate the support group
- C. Completed her “grief work” successfully
- D. Replaced old memories with new ones.
Correct Answer: C
Rationale: The correct answer is C: Completed her "grief work" successfully. This statement indicates progress in the grieving process, moving towards acceptance and healing. The patient acknowledging having more good days than bad reflects a positive shift in coping with the loss, indicating that she has processed her grief and is beginning to adapt to life without her husband. This suggests that the patient has worked through her emotions, memories, and adjustments related to the loss, reaching a point where she is experiencing more peace and acceptance.
Summary:
A: Reestablishment is not the correct choice as it does not specifically address the completion of the grief work.
B: Determining readiness to terminate the support group is premature, as the patient may still benefit from continued support.
D: Replacing old memories with new ones is not supported by the patient's statement and does not necessarily indicate successful grief processing.
A patient living in community housing for the elderly says, “I don’t go to the senior citizens club. They play cards and talk about the past because that’s all they can do.” The nurse analyzes these remarks to represent:
- A. Failure to achieve developmental tasks
- B. Hypercritical behavior
- C. Paranoid thinking
- D. Thinking associated with ageism
Correct Answer: D
Rationale: The correct answer is D: Thinking associated with ageism. This is because the patient's statement reflects a negative stereotype about older adults, assuming they are limited to playing cards and reminiscing about the past. Ageism involves discrimination or prejudice based on someone's age, which can lead to stereotyping and marginalization.
A: Failure to achieve developmental tasks - This choice does not directly relate to the patient's statement about ageism.
B: Hypercritical behavior - The patient's statement does not indicate hypercritical behavior, but rather a biased perspective on aging.
C: Paranoid thinking - The patient's statement does not demonstrate paranoid thinking, but rather a biased view of older adults based on ageist beliefs.
In summary, the correct answer is D as the patient's remarks reflect ageist thinking, while the other choices do not align with the content of the patient's statement.
Which activities should the nurse evaluate in an assessment of an older patient’s functional status? (Select all that apply.)
- A. Possessing the ability to prepare nutritious meals independently.
- B. Having the financial resources available to live independently
- C. Performing regular, simple maintenance on their primary residence.
- D. Effectively toileting themselves for both bowel and bladder elimination.
Correct Answer: A,C
Rationale: The correct answers are A and C. A nurse should evaluate if the older patient can prepare nutritious meals independently, as this indicates their ability to meet basic nutritional needs and maintain independence in daily living. Additionally, assessing if the patient can perform regular, simple maintenance on their primary residence is important for gauging their ability to live safely and comfortably. Choices B and D are incorrect as financial resources and toileting abilities, while important, do not directly reflect functional status in the same way as meal preparation and home maintenance.