Nokea
An elderly patient must be physically restrained. Who is responsible for the patients safety?
- A. The nurse assigned to care for the patient
- B. Unlicensed assistive personnel who apply the restraint
- C. Family member who agrees to application of the restraint
- D. Health care provider who prescribed application of restraint
Correct Answer: A
Rationale: Although restraint is prescribed by a health care provider, the restraint is a measure carried out by nursing staff. The nurse caring for the patient is responsible for safe application of restraining devices and for providing safe care while the patient is restrained. Nurses may delegate the application of restraining devices and the care of the patient in restraint, but the nurse remains responsible for outcomes. Even when family agree to restraint, nurses are responsible for providing safe outcomes.
You may also like to solve these questions
A patient diagnosed with serious mental illness was living successfully in a group home but wanted an apartment. The prospective landlord said, 'People like you have trouble getting along and paying their rent.' The patient and nurse meet for a problem-solving session. Which options should the nurse endorse? Select one tha does not apply.
- A. Coach the patient in ways to control symptoms effectively
- B. Seek out landlords less affected by the stigma associated with mental illness
- C. Threaten the landlord with legal action because of the discriminatory actions
- D. Have the case manager meet with the landlord to provide education about mental illness
Correct Answer: C
Rationale: Managing symptoms so that they are less obvious or socially disruptive can reduce negative reactions and reduce rejection due to stigma. Seeking a more receptive landlord might be the most expeditious route to housing for this patient. Educating the landlord to reduce stigma might make him more receptive and give the case manager an opportunity to address some of his concerns (e.g., the case manager could arrange a payee to assure that the rent is paid each month). However, threatening a lawsuit would increase the landlords defensiveness and would likely be a long and expensive undertaking. Delaying the patients efforts to become more independent is not clinically necessary according to the data noted here; the problem is the landlords bias and response, not the patients illness. It would be unethical to encourage falsification and poor role modeling to do so; further, if falsification is discovered, it could permit the landlord to refuse or cancel her lease.
An elderly woman is brought to the clinic by her daughter. The client states that she has had a cold for several days. Her daughter states that her mother has been confused about when her routine medications are to be taken and that her mother has never experienced confusion before. Based on this information, it is important that the nurse ask the client whether:
- A. There is a history of mental illness in the family.
- B. She has been given a diagnosis of a mental health disorder in the past.
- C. She can recall her last visit to a physician.
- D. None of the above.
Correct Answer: A
Rationale: The correct answer is A: There is a history of mental illness in the family. This is important because the sudden onset of confusion in an elderly person could be indicative of a new mental health issue or cognitive decline. Asking about a family history of mental illness can provide valuable insights into potential genetic predispositions or underlying conditions that may be contributing to the client's confusion.
Choices B and C are incorrect because the client's own history of mental health diagnosis or ability to recall a physician visit are not directly related to the sudden onset of confusion. Choice D is incorrect because asking about a family history of mental illness could provide crucial information in understanding the client's current condition.
Which disorder is often difficult to detect and consequently often goes untreated?
- A. Pica.
- B. Bulimia.
- C. Obesity.
- D. Anorexia nervosa.
Correct Answer: B
Rationale: The correct answer is B: Bulimia. Bulimia is often difficult to detect as individuals may engage in secretive binge eating and purging behaviors. Unlike anorexia nervosa where visible weight loss may be noticeable, individuals with bulimia may maintain a normal weight, making it harder to identify. Bulimia also tends to be associated with feelings of shame and guilt, leading individuals to hide their behaviors. Pica (A) involves eating non-food items and can be more easily observed. Obesity (C) is often noticeable due to visible weight gain. Anorexia nervosa (D) is also easier to detect as individuals may exhibit extreme weight loss and visible physical symptoms.
A nurse is caring for a patient with bulimia nervosa who is experiencing frequent purging. What is a priority assessment?
- A. Monitor electrolyte levels and cardiac function.
- B. Observe for signs of dehydration and low blood pressure.
- C. Assess for any compulsive exercise behaviors.
- D. Monitor for changes in eating patterns and food preferences.
Correct Answer: A
Rationale: The correct answer is A, to monitor electrolyte levels and cardiac function. This is a priority assessment because frequent purging in bulimia nervosa can lead to electrolyte imbalances and cardiac complications, such as arrhythmias and heart failure. Monitoring these parameters is crucial for early detection and intervention to prevent serious health consequences. Observing for signs of dehydration and low blood pressure (Choice B) is important but not as critical as monitoring electrolyte levels and cardiac function. Assessing for compulsive exercise behaviors (Choice C) and monitoring changes in eating patterns and food preferences (Choice D) are also relevant but secondary to the immediate risk of electrolyte imbalances and cardiac issues.
The coping mechanism that patients with anorexia nervosa use maladaptively is:
- A. denial.
- B. projection.
- C. introjection.
- D. rationalization.
Correct Answer: A
Rationale: The correct answer is A: denial. Patients with anorexia nervosa often deny the seriousness of their low weight, distorted body image, or the potential health consequences of their eating behaviors. This denial helps them avoid facing their underlying issues and enables them to continue harmful behaviors. Choice B (projection) involves attributing one's own thoughts or feelings onto others, not relevant to anorexia. Choice C (introjection) involves internalizing external beliefs or values, not a common maladaptive coping mechanism in anorexia. Choice D (rationalization) involves creating logical explanations to justify inappropriate behaviors, not the primary defense mechanism in anorexia.