Nokea
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.
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The nurse in the Emergency Department is taking a history from a family accompanying a child with suspicious traumatic injuries. The nurse should:
- A. Obtain information as covertly as possible
- B. Avoid responding to hints that abuse has occurred
- C. Be open, concerned, and honest
- D. Separate the family from the child during the interview
Correct Answer: C
Rationale: The correct answer is C because being open, concerned, and honest fosters trust, encourages disclosure, and promotes a supportive environment for the family. This approach allows the nurse to gather necessary information effectively and ensure the safety and well-being of the child. Choice A is incorrect as covert behavior may lead to suspicion and hinder communication. Choice B is incorrect because ignoring hints of abuse can be detrimental to the child's safety. Choice D is incorrect as separating the family may escalate tension and prevent crucial information sharing.
A family discusses the impact of a seriously mental ill member. Insurance partially covered treatment expenses, but the family spent much of their savings for care. The patients sibling says, 'My parents have no time for me.' The parents are concerned that when they are older, there will be no one to care for the patient. Which response by the nurse would be most helpful?
- A. Acknowledge their concerns and consult with the treatment team about ways to bring the patients symptoms under better control
- B. Give them names of financial advisors that could help them save or borrow sufficient funds to leave a trust fund to care for their loved one
- C. Refer them to crisis intervention services to learn ways to manage caregiver stress and provide titles of some helpful books for families
- D. Discuss benefits of participating in National Alliance on Mental Illness (NAMI) programs and ways to help the patient become more independent
Correct Answer: D
Rationale: The family has raised a number of concerns, but the major issues appear to be the effects caregiving has had on the family and their concerns about the patients future. The National Alliance on Mental Illness (NAMI) offers support, education, resources, and access to other families who have experience with the issues now facing this family. NAMI can help address caregiver burden and planning for the future needs of SMI persons. Improving the patients symptom control and general functioning can help reduce caregiver burden but would likely be a slow process, whereas NAMI involvement could benefit them on a number of fronts, possibly in a shorter time period. The family will need more than financial planning; their issues go beyond financial. The family is distressed but not in crisis. Crisis intervention is not an appropriate resource for the longer-term issues and needs affecting this family.
The parent of a seriously mentally ill adult asks the nurse, 'Why are you making a referral to a vocational rehabilitation program? My child wont ever be able to hold a job.' Which is the nurses best reply?
- A. We make this referral to continue eligibility for federal funding.'
- B. Are you concerned that were trying to make your child too independent?'
- C. If you think the program would be detrimental, we can postpone it for a time.'
- D. Most patients are capable of employment at some level, competitive or supported.'
Correct Answer: D
Rationale: Studies have shown that most patients who complete vocational rehabilitation programs are capable of some level of employment. They also demonstrate significant improvement in assertiveness and work behaviors as well as decreased depression.
A client with dementia is unable to name ordinary objects. Instead, he describes them (e.g., 'the thing you cut meat with'). The nurse should assess this as:
- A. Aphasia.
- B. Paraphasia.
- C. Apraxia.
- D. None of the above.
Correct Answer: B
Rationale: The correct answer is B: Paraphasia. Paraphasia is a language disturbance characterized by the substitution of one word for another, leading to incorrect or nonsensical speech. In the case of the client with dementia unable to name ordinary objects but describing them, such as 'the thing you cut meat with,' this behavior aligns with paraphasia. Aphasia (choice A) refers to a complete loss or impairment of language function, which is not the case here. Apraxia (choice C) involves the inability to perform purposeful movements, not language deficits. Therefore, the client's behavior is best assessed as paraphasia due to the characteristic word substitutions and descriptions given.
The nurse at the clinic is interviewing a patient who offers a number of vague somatic complaints that might not ordinarily prompt a visit to a caregiver: fatigue, back pain, and seems tense. After having spoken of the symptoms, the nurse can best serve the patient by:
- A. Asking if the patient has ever had psychiatric counseling.
- B. Completing a structured abuse assessment protocol.
- C. Suggesting the patient take a break from work.
- D. None of the above.
Correct Answer: B
Rationale: The correct answer is B: Completing a structured abuse assessment protocol. In this scenario, the patient presents with vague somatic complaints that could potentially be indicative of underlying abuse. By completing an abuse assessment protocol, the nurse can uncover any possible abuse the patient may be experiencing, which could be the root cause of their symptoms. This approach is crucial in ensuring the patient's safety and well-being.
Choice A is incorrect because assuming the symptoms are solely related to psychiatric issues without exploring other potential causes can lead to overlooking important factors. Choice C is incorrect as suggesting a break from work may not address the underlying issue and could potentially worsen the patient's situation. Choice D is incorrect as taking no action could result in the patient's condition worsening without proper intervention.