Nokea
An 85-year-old has difficulty walking after a knee replacement. The patient tells the nurse, 'Its awful to be old. Every day is a struggle. No one cares about old people.' Select the nurses best response.
- A. Everyone here cares about old people. Thats why we work here.'
- B. It sounds like youre having a difficult time. Tell me about it.'
- C. Lets 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 nurse uses empathetic understanding to permit the patient to express frustration and clarify her struggle for the nurse. The distracters block communication.
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An appropriate intervention for a client with an identified nursing diagnosis of Situational low self-esteem would be:
- A. Encouraging verbalization of feelings in a safe environment
- B. Attempting to determine triggers to hallucinations
- C. Engaging client in activities designed to permit success
- D. Providing large muscle activities to relieve stress
Correct Answer: C
Rationale: The correct answer is C: Engaging client in activities designed to permit success. This intervention is appropriate for addressing situational low self-esteem as it focuses on building the client's self-confidence through successful experiences. Engaging in activities that the client can excel at helps boost self-esteem and self-worth. By providing opportunities for success, the client can gain a sense of accomplishment, leading to improved self-esteem.
A: Encouraging verbalization of feelings in a safe environment may be beneficial for emotional expression, but it does not directly address building self-esteem through success.
B: Attempting to determine triggers to hallucinations is unrelated to addressing situational low self-esteem.
D: Providing large muscle activities to relieve stress may be helpful for stress management but does not directly target improving self-esteem through success.
A patient is admitted to the inpatient unit with a diagnosis of schizophrenia. The patient has had episodes of school absenteeism, withdrawal from friends, and bizarre behavior, including talking to his or her 'keeper.' The psychiatric-mental health nurse's most appropriate response is to:
- A. acknowledge that the patient's perceptions seem real to him or her, and refocus the patient's attention on a task or activity
- B. encourage the patient to express his or her thoughts, to determine the meaning they have for the patient
- C. ignore the patient's bizarre behavior, because it will diminish after he or she has been given the correct medication
- D. inform the patient that his or her perceptions of reality have become distorted because of the illness
Correct Answer: A
Rationale: Validating the patient's experience while redirecting to reality-based activity builds trust and reduces agitation without confrontation.
Which documentation indicates that the treatment plan for a patient with acute mania was effective?
- A. Converses without interrupting; clothing matched; participates in activities.
- B. Irritable; suggestible; distractible; napped for 10 minutes in afternoon.
- C. Attention span 1 to 3 minutes; journals frequently about unit activities.
- D. Heavy makeup; seductive toward staff; pressured speech.
Correct Answer: A
Rationale: The correct answer is A because the behaviors described indicate that the patient is able to converse without interrupting, their clothing matches, and they participate in activities. These behaviors suggest improved impulse control, stable mood, and engagement in daily activities, indicating effectiveness of the treatment plan.
Choice B describes symptoms of mania such as irritability and distractibility, which would indicate ongoing symptoms rather than improvement. Choice C indicates a short attention span and excessive journaling, which are not indicative of effective treatment. Choice D describes behaviors suggestive of hypersexuality and pressured speech, which are not signs of improvement in acute mania.
A client with dementia is unable to name ordinary objects. Instead, he describes the function of each item (e.g., 'the thing you cut meat with'). The nurse should assess this as:
- A. Apraxia
- B. Agnosia
- C. Aphasia
- D. Amnesia
Correct Answer: B
Rationale: The correct answer is B: Agnosia. Agnosia is the inability to recognize or identify objects despite intact sensory function. In this case, the client can describe the function of objects but cannot name them, indicating a deficit in object recognition. Apraxia (choice A) is the inability to perform learned movements, aphasia (choice C) is a language impairment, and amnesia (choice D) is memory loss, none of which fully explain the client's presentation.
Persons who suffer from paraphilias are categorized as having
- A. somatoform disorders
- B. generalized anxiety
- C. sexual disorders
- D. personality disorders
Correct Answer: C
Rationale: Paraphilias are classified as sexual disorders, involving atypical sexual interests causing distress or harm.