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An older adult diagnosed with dementia lives with family and attends day care. After observing poor hygiene, the nurse at the center talks with the patient's adult child. This caregiver becomes defensive and says, 'It takes all my time and energy to care for my mother. She's awake all night. I never get any sleep.' Which nursing intervention has priority?
- A. Teach the caregiver more about the effects of dementia.
- B. Secure additional resources for the mother's evening and night care.
- C. Support the caregiver to grieve the loss of the mother's ability to function.
- D. Teach the family how to give physical care more effectively and efficiently.
Correct Answer: B
Rationale: The patient's child and family were coping with care until the patient began to stay awake at night. The family needs assistance with evening and night care to resume their pre-crisis state of functioning. Secondary prevention calls for the nurse to mobilize community resources to relieve overwhelming stress. The other interventions may then be accomplished.
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A nurse visits the home of an 11-year-old child and finds the child caring for three younger siblings. Both parents are at work. The child says, 'I want to go to school but we can't afford a babysitter. It doesn't matter; I'm too dumb to learn.' What preliminary assessment is evident?
- A. Insufficient data are present to make an assessment.
- B. Child and siblings are experiencing neglect.
- C. Children are at high risk for sexual abuse.
- D. Children are experiencing physical abuse.
Correct Answer: B
Rationale: A child is experiencing neglect when the parents take away the opportunity to attend school. The other children may also be experiencing physical neglect, but more data should be gathered before making the actual assessment. The information presented does not indicate a high risk for sexual abuse, and no concrete evidence of physical abuse is present.
An older adult, diagnosed with Alzheimer's disease, lives with family and has multiple bruises. The home health nurse talks with the older adult's daughter, who becomes defensive and says, 'My mother often wanders at night. Last night she fell down the stairs.' Which nursing diagnosis has priority?
- A. Risk for injury, related to cognitive impairment and lack of caregiver supervision
- B. Noncompliance, related to confusion and disorientation as evidenced by lack of cooperation
- C. Impaired verbal communication, related to brain impairment as evidenced by the confusion
- D. Insomnia, related to cognitive impairment as evidenced by wandering at night
Correct Answer: A
Rationale: The patient is at high risk for injury because of her confusion. The risk increases when caregivers are unable to provide constant supervision. No assessment data support the diagnoses of impaired verbal communication or noncompliance. Sleep pattern disturbance certainly applies to this patient; however, the diagnosis risk for injury is a higher priority.
Which family scenario presents the greatest risk for family violence?
- A. An unemployed husband with low self-esteem, a wife who loses her job, and a developmentally delayed 3-year-old child
- B. A husband who finds employment 2 weeks after losing his previous job, a wife with stable employment, and a child diagnosed with attention deficit disorder
- C. A single mother with an executive position, a gifted and talented child, and a widowed grandmother living in the home to provide child care
- D. A single homosexual male parent and an adolescent son who has just begun dating girls
Correct Answer: A
Rationale: The family with an unemployed husband with low self-esteem, a newly unemployed wife, and a developmentally challenged young child has the greatest number of stressors. The other families described have fewer negative events occurring.
Which rationale best explains why a nurse should be aware of personal feelings while working with a family experiencing family violence?
- A. Self-awareness protects one's own mental health.
- B. Strong negative feelings interfere with assessment and judgment.
- C. Strong positive feelings lead to under involvement with the victim.
- D. Positive feelings promote the development of sympathy for patients.
Correct Answer: B
Rationale: Strong negative feelings cloud the nurse's judgment and interfere with assessment and intervention, no matter how well the nurse tries to cover or deny personal feelings. Strong positive feelings lead to overinvolvement with the victim.
What feelings are most commonly experienced by nurses working with abusive families?
- A. Outrage toward the victim and sympathy for the abuser
- B. Sympathy for the victim and anger toward the abuser
- C. Unconcern for the victim and dislike for the abuser
- D. Vulnerability for self and empathy with the abuser
Correct Answer: B
Rationale: Intense protective feelings, sympathy for the victim, and anger and outrage toward the abuser are common emotions of a nurse working with an abusive family.