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An 85-year-old has difficulty walking after a knee replacement. The patient tells the nurse, 'It's awful to be old. Every day is a struggle. No one cares about old people.' Select the nurse's best response.

  • A. Everyone here cares about old people. That's why we work here.
  • B. It sounds like you're having a difficult time. Tell me about it.
  • C. Let's not focus on the negative. Tell me something good.
  • D. You are still able to get around, and your mind is alert.
Correct Answer: B

Rationale: The correct answer is B because it shows empathy and encourages the patient to express their feelings. By saying "Tell me about it," the nurse acknowledges the patient's struggle and opens up the opportunity for the patient to share more about their feelings and concerns. This can help build a therapeutic relationship and provide emotional support.

Choice A is incorrect because it dismisses the patient's feelings by making a general statement about everyone caring without addressing the patient's specific concerns.

Choice C is incorrect because it invalidates the patient's emotions by suggesting to focus on positivity without addressing the patient's current distress.

Choice D is incorrect because it minimizes the patient's struggle by only focusing on physical abilities and cognitive function without addressing the emotional aspect of the patient's statement.

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Schizophrenia in children as young as 5 years:

  • A. Is a myth
  • B. Can occur
  • C. Never occurs
  • D. Cannot occur
Correct Answer: B

Rationale: The correct answer is B: Can occur. Schizophrenia can indeed manifest in children as young as 5 years old, although it is rare. Symptoms may include hallucinations, delusions, disorganized speech, and impaired social interactions. Early diagnosis and intervention are crucial for managing the condition. Choice A is incorrect as schizophrenia in young children is not a myth. Choice C is incorrect as schizophrenia can occur in children. Choice D is incorrect as there have been documented cases of schizophrenia in children as young as 5 years old.

A nurse is providing education to a patient with anorexia nervosa. Which of the following statements indicates a need for further education?

  • A. I understand that my body needs food to function properly.
  • B. I am willing to work on gaining weight with the help of my care team.
  • C. I believe that eating food will make me fat and out of control.
  • D. I am ready to learn how to improve my relationship with food.
Correct Answer: C

Rationale: The correct answer is C because the statement reflects a common misconception associated with anorexia nervosa, indicating a need for further education. Here's the rationale:
1. Anorexia nervosa involves a distorted body image and fear of gaining weight.
2. Believing that eating food will make one fat and out of control aligns with these distorted beliefs.
3. This statement demonstrates a lack of understanding and acceptance of the importance of proper nutrition for health.
4. Choices A, B, and D show positive attitudes towards recovery and willingness to address the disorder, highlighting a better understanding of the condition.
In summary, choice C shows a need for further education due to the presence of distorted beliefs, while the other options reflect a more positive and informed mindset towards recovery.

Select the best comment for a nurse to begin an interview with an elderly patient.

  • A. I am a nurse. Are you familiar with what nurses do?'
  • B. Hello. I am going to ask you some questions to get to know you better.'
  • C. You look comfortable and ready to participate in an admission interview. Shall we get started?'
  • D. Hello. My name is and I am a nurse. How you would like to be addressed by staff?'
Correct Answer: D

Rationale: The correct opening identifies the nurses role and politely seeks direction for addressing the patient in a way that will make him or her comfortable. This is particularly important when a considerable age difference exists between the nurse and the patient. The nurse should address patients by name and not assume patients want to be called by a first name. The nurse should always introduce self.

The home care nurse assessed a client with a history of dementia who had a herniorrhaphy at an ambulatory surgical center the previous day. The client lives in a senior living facility. The client thinks he is in the army and that it is 1945. The nurse should:

  • A. Reorient the client to the current time and place.
  • B. Notify the client's family of the confusion.
  • C. Document the client's confusion and disorientation.
  • D. None of the above.
Correct Answer: A

Rationale: The correct answer is A: Reorient the client to the current time and place. The nurse should reorient the client to prevent distress and promote safety. This approach helps the client feel more secure and may reduce confusion. Choice B is incorrect because the nurse should address the client's needs first. Choice C is not enough on its own as the nurse needs to actively assist the client. Choice D is incorrect as action is needed in this situation to support the client.

A rape victim tells the emergency room nurse, "I feel so dirty. Help me take a shower before the doctor examines me." The nurse should:

  • A. Arrange for the patient to shower.
  • B. Explain that bathing would destroy evidence.
  • C. Give the patient a basin of water and towels.
  • D. Explain that bathing facilities are not available in the emergency department.
Correct Answer: B

Rationale: The correct answer is B: Explain that bathing would destroy evidence. This is the correct choice because bathing can potentially wash away crucial forensic evidence that can be collected during a sexual assault examination. Preserving evidence is essential for legal proceedings and ensuring justice for the victim.

Choice A is incorrect because arranging for the patient to shower would destroy evidence. Choice C is incorrect as giving the patient a basin of water and towels would still risk destroying evidence. Choice D is also incorrect as it does not address the importance of preserving evidence in cases of sexual assault.

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