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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.
Which of the following is a potential complication of untreated bulimia nervosa?
- A. Severe dehydration and electrolyte imbalances.
- B. Rapid weight gain and fluid retention.
- C. Chronic constipation and digestive issues.
- D. Severe malnutrition and organ failure.
Correct Answer: A
Rationale: The correct answer is A: Severe dehydration and electrolyte imbalances. Untreated bulimia nervosa involves recurrent episodes of binge-eating followed by compensatory behaviors like purging. Purging can lead to fluid loss and electrolyte imbalances, causing dehydration. This can result in serious health complications such as cardiac arrhythmias and kidney damage. Rapid weight gain and fluid retention (B) are more associated with binge-eating disorder, not bulimia nervosa. Chronic constipation and digestive issues (C) are more commonly seen in anorexia nervosa. Severe malnutrition and organ failure (D) are potential complications of anorexia nervosa rather than bulimia nervosa.
A 16-year-old female patient who is Chinese American is admitted to the unit with reports of sadness and suicidal ideation. The patient is accompanied by many family members, including her mother and father. The patient and her family emigrated from mainland China five years ago. Regarding the family, the psychiatric-mental health nurse:
- A. encourages the patient to communicate her need for privacy to her family
- B. gently asks the family members to leave the room
- C. privately asks the mother for her assistance in clearing the room
- D. provides care for the patient while the family members are present
Correct Answer: C
Rationale: Involving the mother respects cultural family dynamics while facilitating a private assessment, balancing sensitivity and need.
The emergency department note states, 'This patient displays positive symptoms of schizophrenia as evidenced by psychotic disorders of thinking.' The nurse can expect the patient to evidence:
- A. delusions and hallucinations.
- B. grimacing and mannerisms.
- C. echopraxia and echolalia.
- D. avolition and anhedonia.
Correct Answer: A
Rationale: The correct answer is A: delusions and hallucinations. Positive symptoms of schizophrenia include hallucinations (perceiving things that are not present) and delusions (false beliefs). In this case, the patient displaying psychotic disorders of thinking aligns with positive symptoms. Delusions are fixed false beliefs, while hallucinations involve sensory experiences without external stimuli. Choices B, C, and D involve different symptoms such as motor abnormalities (grimacing and mannerisms), echopraxia and echolalia (mimicking movements and repeating words), and negative symptoms (avolition and anhedonia - lack of motivation and pleasure), which are not specifically related to psychotic disorders of thinking in schizophrenia.
A short-term goal for a patient with anorexia nervosa is 'Patient will select and eat a balanced diet.' The nurse writes which of the following nursing interventions into the care plan that will foster attainment of this goal?
- A. Allow patient to weigh self every time a meal is completely eaten.
- B. Assist the patient to fill out the dietary menus to ensure a balanced diet.
- C. Encourage the patient to engage in only appropriate compensatory exercise.
- D. Implement contracted consequences 50% of the time if a meal is not completed.
Correct Answer: B
Rationale: The correct answer is B: Assist the patient to fill out the dietary menus to ensure a balanced diet. This intervention is appropriate because it directly supports the goal of the patient selecting and eating a balanced diet. By assisting the patient in filling out dietary menus, the nurse can help the patient make informed choices about their food intake, ensuring they are consuming a variety of nutrients necessary for a balanced diet. This intervention promotes patient autonomy and education, empowering the patient to make healthier choices.
Choice A is incorrect because allowing the patient to weigh themselves every time a meal is eaten does not directly address the goal of selecting and eating a balanced diet.
Choice C is incorrect because encouraging compensatory exercise may lead to unhealthy behaviors and does not focus on achieving a balanced diet.
Choice D is incorrect because implementing contracted consequences for incomplete meals may create a negative environment and does not promote a positive approach to achieving a balanced diet.