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An appropriate nursing intervention for this patient?
- A. Post clocks and calendars in the patient's environment.
- B. Establish and consistently follow a daily schedule with the patient.
- C. Monitor the patient's activities to maintain a safe patient environment.
- D. Stimulate thought processes by asking the patient questions about recent activities.
Correct Answer: B
Rationale: Consistent schedules help orient patients with dementia
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Early in the care of the patient diagnosed with a right-sided brain stroke and disturbed visual sensory perception related to homonymous hemianopsia, what should the nurse do?
- A. Place objects on the right side within the patient's field of vision.
- B. Approach the patient from the left side to encourage the patient to turn the head.
- C. Place objects on the patient's left side to assess the patient's ability to compensate.
- D. Patch the affected eye to encourage the patient to turn the head to scan the environment.
Correct Answer: B
Rationale: Encouraging the patient to turn their head helps them become aware of their blind side
You are caring for a patient who is preoperative and is NPO. The patient takes carbamazepine (Tegretol), 200 mg PO BID for a seizure disorder. Which of the following actions should you take?
- A. Give the oral dose of carbamazepine with a sip of water.
- B. Give carbamazepine IV.
- C. Withhold the carbamazepine.
- D. Administer half the usual morning dose of carbamazepine.
Correct Answer: A
Rationale: It is important to continue the oral carbamazepine to maintain therapeutic blood levels and to prevent seizure activity. You should notify the anesthesiologist and should give the patient the carbamazepine with a sip of water. Carbamazepine is not available IV. Withholding the carbamazepine may reduce the therapeutic blood level and cause seizure activity. Administering a reduced dose of carbamazepine may reduce the therapeutic blood level and cause seizure activity.
A patient says, I feel detached and weird all the time, like I'm looking at life through a cloudy window. Everything seems unreal. These feelings really interfere with my work and study. Which term should the nurse use to document this complaint?
- A. Depersonalization
- B. Hypochondriasis
- C. Dissociation
- D. Malingering
Correct Answer: A
Rationale: Correct Answer: A. Depersonalization
Rationale:
1. Depersonalization involves feeling detached from oneself or reality, as described by the patient.
2. The patient's description of feeling like they are looking through a cloudy window aligns with depersonalization symptoms.
3. Interference with work and study suggests significant distress, a common feature of depersonalization disorder.
Summary of other choices:
B. Hypochondriasis: Involves excessive worry about having a serious illness, which is not indicated in the patient's complaint.
C. Dissociation: While depersonalization is a type of dissociative symptom, it specifically refers to feeling detached and unreal, not necessarily a broader dissociative disorder.
D. Malingering: Involves feigning or exaggerating symptoms for secondary gain, which is not evident in the patient's genuine distress and impairment.
Without surgical stabilization, what method of immobilization for the patient with a cervical spinal cord injury should the nurse expect to be used?
- A. Kinetic beds
- B. Hard cervical collar
- C. Skeletal traction with skull tongs
- D. Sternal-occipital-mandibular immobilizer brace
Correct Answer: D
Rationale: This brace provides rigid immobilization.
The following conditions are required for rhodopsin regeneration:
- A. NADPH
- B. darkness
- C. splitting of all trans-retinal from the opsin
- D. all above
Correct Answer: D
Rationale: Rhodopsin regeneration requires NADPH, darkness, and the separation of all-trans-retinal from opsin. These steps are essential for the visual cycle.