According to Maslow’s hierarchy of needs, which nursing strategies would assist in meeting self-esteem needs of elderly patients?
- A. Providing privacy when spouses are visiting
- B. Arranging for the spouses to dine with the patients when visiting
- C. Including both the patients and spouses in all educational sessions
- D. Attending to patient hygiene and dress in preparation for spousal visits
Correct Answer: D
Rationale: Step-by-step rationale for why choice D is correct:
1. Maslow's hierarchy of needs places self-esteem as a fundamental psychological need.
2. Patient hygiene and dress contribute to self-esteem by promoting a sense of dignity and self-worth.
3. Attending to hygiene and dress before spousal visits shows respect for the patient's self-esteem.
4. This strategy directly addresses the self-esteem needs of elderly patients by enhancing their sense of self-worth and respect.
Summary of why other choices are incorrect:
A: Providing privacy for spouses does not directly address the patient's self-esteem needs.
B: Arranging dining with spouses may enhance social needs but not directly address self-esteem.
C: Including patients and spouses in educational sessions may promote social interaction but does not directly target self-esteem needs.
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Which statement by a patient who has given informed consent for ECT confirms that the patient understands the side effects of this treatment?
- A. “It will take several weeks before I feel good again.”
- B. "I won’t need any further treatments after completing this one session."
- C. “My short-term memory loss will be only temporary."
- D. "This treatment guarantees that my depression will never come back."
Correct Answer: C
Rationale: The correct answer is C because it accurately reflects the known side effect of ECT, which is temporary short-term memory loss. This statement indicates the patient comprehends the potential cognitive impact of the treatment.
A is incorrect because it does not address specific side effects of ECT. B is incorrect as it implies a misconception that only one session is needed. D is incorrect as ECT does not guarantee that depression will never return.
A new nurse asks, “My elderly patient has Lewy body disease. What should I do about assessing for pain?” Select the best response from the nurse manager.
- A. Ask the patient’s family if they think the patient is experiencing pain.
- B. Use a visual analog scale to help the patient determine the presence and severity of pain.
- C. There are special scales for assessing patients with dementia. Let’s review how to use them.
- D. The perception of pain is diminished by this type of dementia. Focus your assessment on the patient’s mental status.
Correct Answer: C
Rationale: The correct answer is C because Lewy body disease can affect a patient's ability to communicate pain, making specialized pain assessment tools crucial. Special scales designed for patients with dementia can help in accurately assessing pain levels. These tools consider non-verbal cues and behavioral changes that may indicate pain. Asking the patient's family (A) may not always provide an accurate assessment of pain perception. Using a visual analog scale (B) may be challenging for a patient with cognitive impairment. Focusing solely on mental status (D) may overlook important indicators of pain in patients with Lewy body disease.
Planning safety interventions for a teenager with a history of self-injurious behavior is based on what research-based information?
- A. Teenagers rarely entertain the idea of suicide.
- B. Self-injury is always viewed as a risk factor for future suicidal attempts.
- C. Assessment for suicidal ideations is a vital component of this child's care.
- D. Suicides can occur accidentally as a result of self-injurious behaviors.
Correct Answer: D
Rationale: The correct answer is D because research indicates that suicides can occur accidentally as a result of self-injurious behaviors. This is known as an unintentional suicide, where the individual did not intend to die but died due to the severity of their self-injurious behavior. This information is crucial for planning safety interventions for the teenager, as it highlights the potential seriousness of self-injury.
Choice A is incorrect because research shows that suicidal ideation is not uncommon among teenagers, so it cannot be assumed that they rarely entertain the idea of suicide. Choice B is also incorrect because while self-injury can be a risk factor for future suicidal attempts, it is not always the case. Choice C is relevant but not the most specific to the scenario presented in the question, as it focuses solely on suicidal ideations rather than the potential accidental outcomes of self-injury.
Which developmental level would be characterized by a child being able to focus, coordinate, and imagine a series of events?
.
- A. Preoperational
- B. Concrete operational
- C. Formal operational
- D. Postoperational
Correct Answer: B
Rationale: The correct answer is B: Concrete operational. At this developmental level, children typically exhibit the ability to focus, coordinate, and imagine a series of events. This stage, according to Piaget's theory, usually occurs around ages 7 to 11. Children at this stage can perform logical operations, understand conservation, and think more systematically.
A: Preoperational - Children at this stage (ages 2-7) lack the ability to perform logical operations and struggle with understanding conservation and cause-and-effect relationships.
C: Formal operational - This stage (typically starting around age 11) involves abstract thinking, hypothetical reasoning, and problem-solving beyond the concrete level.
D: Postoperational - This term is not a recognized developmental stage in Piaget's theory.
Which response by the nurse would best assist a patient in de-escalating aggressive behavior?
- A. "Tell me what’s going on."
- B. "Why are you getting so upset?"
- C. "If you throw something, you will be restrained."
- D. "It’s time for group therapy. You can talk there."
Correct Answer: A
Rationale: The correct answer is A because it demonstrates active listening and shows empathy towards the patient, which can help them feel heard and understood. By inviting the patient to express their feelings and concerns, the nurse can help de-escalate the situation by addressing the underlying issues.
Choice B is incorrect because it may come across as confrontational and could further provoke the patient's aggression. Choice C is also incorrect as it threatens the patient with consequences, which can escalate the situation. Choice D is not appropriate as it distracts from addressing the current issue of aggression and may not be well-received by the patient in that moment.