According to Piaget, which of the following would the nurse consider normal when assessing a 6-year-old?
- A. Playing with an imaginary friend
- B. Talking about their best friend
- C. Enjoying putting puzzles together
- D. Knowing it’s wrong to tell a lie
Correct Answer: C
Rationale:
At 6 years old, children are typically in the concrete operational stage of development, characterized by logical thinking and enjoyment of problem-solving activities like puzzles.
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When asked, “Why do you go to music therapy every morning at 10?” The nurse explains that the nurse’s role in music therapy as:
- A. Fostering and encouraging performance talent
- B. Teaching patients about various styles of music
- C. Noting patient verbal and nonverbal expression of feelings
- D. Selecting and playing numbers that will reduce anxiety and stress
Correct Answer: C
Rationale: The nurse's role in music therapy is to note patient verbal and nonverbal expression of feelings. In music therapy, the focus is on using music as a tool to help patients express themselves, connect with their emotions, and communicate their feelings in a non-verbal manner. The nurse's job is to observe and interpret how the patients are engaging with the music and using it as a medium to express their inner thoughts and emotions. This can help in promoting emotional well-being and providing a space for patients to process their feelings in a therapeutic way.
During a grief-processing group, an elderly patient stated, For the first time since my husband died, Im having more good days than bad. This statement suggests that the patient has:
- A. Replaced old memories with new ones
- B. Reached the phase of reestablishment
- C. Completed her grief work successfully
- D. Determined she is ready to terminate the support group
Correct Answer: B
Rationale: Reestablishment is a phase of grief characterized by finding balance, experiencing positive moments, and reduced intensity of sadness.
Which assessment finding should be considered a high risk factor for adolescent suicide?
- A. Being sexually abused.
- B. Having experienced panic attacks
- C. Being mildly cognitively impaired
- D. Having a diagnosis of type 1 diabetes
Correct Answer: A
Rationale: Adolescents who have been sexually abused are at a higher risk for suicide. Trauma can significantly impact mental health, increasing the risk of depression, self-harm, and suicidal thoughts.
Which patient would the nurse determine to be at highest risk for dysfunctional grief? The patient:
- A. Whose 16-year-old daughter was raped and killed while going on an errand for the patient
- B. Whose 86-year-old mother, with whom she has shared her home, died after a long illness.
- C. Who attended a support group and had been assisted by hospice to care for her terminally ill husband
- D. Who attended a bereavement group, where she learned to express feelings after the deaths of her twin daughters
Correct Answer: A
Rationale: The patient whose 16-year-old daughter was raped and killed while going on an errand for the patient would be determined to be at highest risk for dysfunctional grief. This traumatic event involves sudden and violent loss of a child, which can lead to complicated or dysfunctional grief reactions. The circumstances of the death, involving violence, unexpectedness, and the close relationship with the deceased, can significantly impact the grieving process. The patient may struggle with intense emotions, guilt, anger, and unresolved trauma, making them more vulnerable to experiencing dysfunctional grief. It is essential for healthcare professionals to provide appropriate support and interventions to help the patient navigate through this complex grieving process.
Which statement would the nurse use to describe the primary purpose of boundaries?
- A. Boundaries define responsibilities and duties to one’s self in relation to others.
- B. Boundaries determine objectives of the various working stage of the relationship.
- C. Boundaries differentiate the assumed roles of both the nurse and of the patient.
- D. Boundaries prevent undesired material from emerging during the interaction.
Correct Answer: A
Rationale: Boundaries define responsibilities and duties to one’s self in relation to others. Setting boundaries is essential in establishing a safe and professional therapeutic relationship between a nurse and a patient. These boundaries help to create a clear understanding of each person's roles and responsibilities within the relationship. Boundaries also help protect both the nurse and the patient from potential harm, maintain professionalism, and ensure effective communication and focus on the therapeutic goals. By defining these boundaries, the nurse can better maintain appropriate relationships with patients and avoid conflicts of interest or ethical dilemmas.