Nokea
An older adult with Lewy body dementia lives with family. After observing multiple bruises, the home health nurse talked with the daughter, who became defensive and said, My mother often wanders at night. Last night she fell down the stairs. Which nursing diagnosis has priority?
- A. Risk for injury related to poor judgment, cognitive impairments, and inadequate supervision
- B. Wandering related to confusion and disorientation as evidenced by sleepwalking and falls
- C. Chronic confusion related to degenerative changes in brain tissue as evidenced by nighttime wandering
- D. Insomnia related to sleep disruptions associated with 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 give constant supervision. Insomnia, chronic confusion, and wandering apply to this patient; however, the risk for injury is a higher priority.
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The most appropriate nursing intervention with Jenny (from question 5) would be to:
- A. Make arrangements for her to start attending Alateen meetings.
- B. Help her identify the positive things in her life and recognize that her situation could be a lot worse than it is.
- C. Teach her about the effects of alcohol on the body and that it can be hereditary.
- D. Refer her to a psychiatrist for private therapy to learn to deal with her home situation.
Correct Answer: A
Rationale: The correct answer is A because Alateen meetings provide support and understanding for teenagers living with family members struggling with alcoholism. Attending these meetings can help Jenny feel less alone, gain coping strategies, and build a support network with peers in similar situations.
Choice B is incorrect as it minimizes Jenny's struggles and may invalidate her feelings. Choice C focuses on the biological aspect of alcoholism, which may not address Jenny's emotional needs. Choice D involves a referral to a psychiatrist for private therapy, which may not provide the peer support and understanding that Alateen meetings can offer.
is a set of observable and measurable actions.
- A. Emotions
- B. Thoughts
- C. Behaviour
- D. Attitude
Correct Answer: C
Rationale: Behavior refers to observable, measurable actions, distinguishing it from internal states like emotions.
The Montessori classrooms are
- A. Teacher-centered
- B. Child-centered
- C. Curriculum-centered
- D. Activity-centered
Correct Answer: B
Rationale: Montessori classrooms prioritize the child's autonomy and exploration.
When providing instructions to a patient who has just been prescribed Isocarboxazid (Marplan), it is important for the nurse to include:
- A. Interactions with other medications
- B. Requires tyramine-free diet: avoid food and drugs that increase norepinephrine levels to prevent hypertensive crisis
- C. Palpitations
- D. Course hand tremor
Correct Answer: A
Rationale: The correct answer is A because Isocarboxazid is an MAOI, which can have dangerous interactions with other medications resulting in serious side effects. It is crucial for the nurse to educate the patient about potential drug interactions to prevent harm. Choice B is incorrect as Isocarboxazid does not require a tyramine-free diet like other MAOIs such as phenelzine. Choices C and D are unrelated side effects of Isocarboxazid and not the key information that needs to be communicated to the patient.
Which statement demonstrates an understanding of the value of using rating scales when assessing and documenting client responses?
- A. Documentation is standardized for all depressed clients when you use the depression rating scale.'
- B. The depression rating scale makes tracing a client's response to antidepressant medication much more reliable.'
- C. Clients seem to be able to assign a number to their feelings of depression better than describing them verbally.'
- D. Depressed clients seldom have the energy to adequately respond to an assessment if a depression rating scale isn't used.'
Correct Answer: B
Rationale: The correct answer is B because using a rating scale, like the depression rating scale, provides a quantifiable measure of a client's depressive symptoms, allowing for a more objective assessment and tracking of changes over time. It enhances reliability by standardizing the evaluation process and making it easier to monitor the effectiveness of interventions, such as antidepressant medication. This choice highlights the value of rating scales in clinical practice.
Incorrect answers:
A: This choice focuses on standardization of documentation but doesn't directly address the value of using rating scales for assessing client responses.
C: While clients may find it easier to assign a number to their feelings, this does not specifically relate to the benefits of using rating scales in assessment and documentation.
D: This choice makes assumptions about the energy levels of depressed clients and does not address the key point of the question about the value of using rating scales for assessment and documentation.