Nokea
After undergoing two of nine electroconvulsive therapy (ECT) procedures, a client states, "I can’t even remember eating breakfast, so I want to stop the ECT." Which is the most appropriate nursing reply?
- A. After you begin the course of treatments, you must complete all of them.
- B. You’ll need to talk with your doctor about what you’re thinking
- C. It is within your right to discontinue the treatments, but let’s talk about your concerns.
- D. Memory loss is a rare side effect of the treatment. I don’t think it should be a concern.
Correct Answer: C
Rationale: The correct answer is C. It acknowledges the client's autonomy while also addressing their concerns. First, it recognizes the client's right to discontinue treatment. Second, it opens the door for a discussion to explore the client's worries and provide support. This response shows empathy and respects the client's decision-making.
Choice A is incorrect because it dismisses the client's autonomy and fails to address their concerns. Choice B is not as appropriate as it suggests only talking to the doctor, missing the opportunity for the nurse to provide immediate support. Choice D is incorrect as it invalidates the client's experience of memory loss and fails to address their concerns.
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The nurse counseling a patient with acute grief would assess the patient for:
- A. Severe depressive symptoms
- B. Conflicted and unresolved issues
- C. Increased arousal and hypervigilance
- D. Preoccupation with the image of the deceased
Correct Answer: B
Rationale: The correct answer is B because acute grief typically involves conflicting and unresolved emotions and thoughts related to the loss. The nurse would assess for unresolved issues to provide appropriate support and interventions. Choice A is incorrect as severe depressive symptoms may indicate complicated grief, not typical acute grief. Choice C is incorrect as increased arousal and hypervigilance are more characteristic of post-traumatic stress disorder. Choice D is incorrect as preoccupation with the image of the deceased may be a common experience in grief but does not encompass the full range of emotions and conflicts that acute grief entails.
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.
Which intervention best reflects the nursing role regarding effective implementation of behavioral therapy goals?
- A. Administering the prescribed medications accurately
- B. Interacting effectively with members of the health care team
- C. Being aware of all the patient related therapeutic modalities
- D. Evaluating patient behaviors to reward economic tokens appropriately
Correct Answer: D
Rationale: The correct answer is D because evaluating patient behaviors to reward economic tokens appropriately is a key aspect of behavioral therapy. By assessing and reinforcing positive behaviors with rewards, nurses can encourage patients to continue working towards their therapy goals. Administering medications accurately (choice A) is important but not directly related to behavioral therapy goals. Interacting effectively with the health care team (choice B) is important for overall patient care but does not specifically address behavioral therapy. Being aware of therapeutic modalities (choice C) is important but does not directly contribute to implementing behavioral therapy goals like choice D does.
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.
A patient asks, “What advantage does a durable power of attorney for health care have over a living will?” The nurse should reply, A durable power of attorney for health care:
- A. Gives your agent authority to make decisions during any illness if you are incapacitated.
- B. Can be given only to a relative, usually the next of kin, who has your best interests at heart.
- C. Can be used only if you have a terminal illness and become incapacitated.
- D. Cannot be implemented until 30 days after the documents are signed.
Correct Answer: A
Rationale: Correct Answer: A: Gives your agent authority to make decisions during any illness if you are incapacitated.
Rationale:
1. A durable power of attorney for health care allows you to appoint a trusted individual (agent) to make medical decisions on your behalf if you are unable to do so.
2. This authority is not limited to a specific type of illness or condition, ensuring your agent can make decisions for any illness that renders you incapacitated.
3. This flexibility ensures that your wishes are carried out regardless of the circumstances.
Summary of Other Choices:
B: Incorrect - A durable power of attorney can be given to any trusted individual, not just a relative.
C: Incorrect - A durable power of attorney can be used in any situation where you are unable to make decisions, not just in terminal illness.
D: Incorrect - A durable power of attorney can be implemented immediately upon signing, providing timely decision-making support.