An appropriate outcome for a patient with a personality disorder and a nursing diagnosis of Ineffective coping as evidenced by use of manipulation would be that the patient will:
- A. refrain from manipulative behavior at all times
- B. use manipulation only to get legitimate needs met
- C. acknowledge manipulative behavior when it is pointed out
- D. identify when he is experiencing feelings of anger
Correct Answer: C
Rationale: Rationale: Choice C is correct as it focuses on the patient acknowledging manipulative behavior when pointed out. This is important for growth and self-awareness in handling emotions and behaviors effectively. Choices A and B are extreme and unrealistic expectations, as complete cessation or selective use of manipulation may not be achievable. Choice D is irrelevant to the nursing diagnosis and does not address the core issue of ineffective coping through manipulation.
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What is an important aspect of managing refeeding syndrome in patients with anorexia nervosa?
- A. Refeeding the patient with high-calorie foods immediately.
- B. Monitoring electrolytes closely during the refeeding process.
- C. Allowing the patient to eat whatever they want without restrictions.
- D. Restricting fluid intake to avoid water retention.
Correct Answer: B
Rationale: The correct answer is B because monitoring electrolytes closely during refeeding is crucial to prevent life-threatening complications such as electrolyte imbalances. Refeeding syndrome can lead to shifts in electrolytes, particularly phosphorus, potassium, and magnesium, which may result in cardiac arrhythmias, respiratory failure, or even death. Close monitoring allows for timely interventions to maintain electrolyte balance.
Choice A is incorrect because refeeding a patient with high-calorie foods immediately can actually exacerbate refeeding syndrome by overwhelming the body's metabolic and electrolyte regulation processes. Choice C is incorrect because allowing the patient to eat whatever they want without restrictions can lead to rapid and uncontrolled weight gain, which may worsen medical complications. Choice D is incorrect because restricting fluid intake can also contribute to electrolyte imbalances and dehydration during refeeding.
A common nursing diagnosis for a patient with antisocial personality disorder is:
- A. chronic low self-esteem, related to poor self-image and excessive fear of failure
- B. disturbed thought processes, related to sensory-perceptual alterations
- C. impaired social interaction, related to manipulative behaviors
- D. social isolation, related to anxiety in social situations
Correct Answer: C
Rationale: Impaired social interaction due to manipulation reflects the interpersonal challenges of antisocial personality disorder.
A client in the cardiac clinic tells the nurse that he is concerned about his mother, age 75, who lives alone and seems more forgetful. Which statement would be most indicative that the mother may have Alzheimer's disease?
- A. Mom continues to participate in senior center activities each week.'
- B. Mom insists on cooking and cleaning for herself.'
- C. Mom forgot to pay her utility bills last month.'
- D. Mom refuses to stop driving even though her reaction time is very slow.'
Correct Answer: C
Rationale: The correct answer is C because forgetting to pay bills is a common early symptom of Alzheimer's disease due to cognitive decline affecting memory and executive functions. This behavior indicates difficulty with organizing and managing tasks, a hallmark of Alzheimer's. Choices A and B suggest independence and engagement, which are not necessarily indicative of Alzheimer's. Choice D hints at potential safety concerns but does not directly point to cognitive decline related to Alzheimer's.
A client with moderate to severe dementia does not remember her son's name. The son repeatedly questions the mother when he visits the dementia facility, asking, 'Do you know my name?' The mother invariably becomes agitated. The nurse can most effectively intervene by explaining to the son:
- A. Your mother is angry with you and is punishing you by 'forgetting' who you are. Be patient and she'll get over it.'
- B. I know it is difficult for you, but your mother's dementia is severe and she cannot retain information even for short periods of time. She senses your distress and becomes agitated.'
- C. Although it's a strain for you, you will need to reorient your mother as often as you can, during the time you are with her. With repetition, she may be able to understand and recall what you are saying.'
- D. Because you become so distressed, it might be better if you come to see your mother only once a week and stay for only a short time.'
Correct Answer: B
Rationale: Rationale:
1. Correct Answer (B): Explains the son's mother's inability to retain information due to severe dementia, causing agitation. Validates son's feelings and provides insight into the mother's behavior.
2. Incorrect Answer (A): Falsely suggests the mother is punishing the son by forgetting, potentially causing misunderstanding and blame.
3. Incorrect Answer (C): Implies the son should solely focus on reorienting the mother, overlooking the emotional impact and distress caused by repetitive questioning.
4. Incorrect Answer (D): Suggests limiting visits based on the son's distress, rather than addressing the root cause of agitation caused by the mother's dementia.
A nurse and social worker co-lead a reminiscence group for eight young-old adults. Which activity is most appropriate to include in the group?
- A. Mild aerobic exercise
- B. Singing a song from World War II
- C. Discussing national leadership during the Vietnam War
- D. Identifying the most troubling story in today's newspaper
Correct Answer: C
Rationale: The correct answer is C. Discussing national leadership during the Vietnam War is most appropriate as it aligns with the reminiscence therapy goal of recalling past experiences to promote social interaction and cognitive stimulation. It is relevant to the age group of young-old adults who may have lived through that era, sparking meaningful discussions. Choice A does not directly relate to reminiscence therapy. Choice B may not resonate with all group members. Choice D focuses on negative news, which is not conducive to the therapeutic purpose.