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An older adult with Lewy body dementia lives with family and attends a day care center. A nurse at the day care center noticed the adult had a disheveled appearance, strong odor of urine, and bruises on the limbs and back. What type of abuse might be occurring?
- A. Psychological
- B. Financial
- C. Physical
- D. Sexual
Correct Answer: C
Rationale: Lewy body dementia results in cognitive impairment. The assessment of physical abuse would be supported by the nurses observation of bruises. Physical abuse includes evidence of improper care as well as physical endangerment behaviors, such as reckless behavior toward a vulnerable person that could lead to serious injury. No data substantiate the other options.
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How many things in common nearly all good days:
- A. Two
- B. Three
- C. Four
- D. Five
Correct Answer: B
Rationale: Lyubomirsky suggests 3 common elements (e.g., positivity, connection, achievement) for good days.
The lack of necessary supplies and equipment to adequately and safely care for patients is an example of a (n):
- A. Sentinel event.
- B. System variance.
- C. Adverse effect.
- D. Provider variance.
Correct Answer: B
Rationale: System variances involve deficiencies in resources or processes.
A patient comes to an outpatient appointment obviously intoxicated. The nurse should:
- A. explore the patient’s reasons for drinking today.
- B. arrange admission to an inpatient psychiatric unit.
- C. coordinate emergency admission to a detoxification unit.
- D. tell the patient, 'We cannot see you today because you’ve been drinking.'
Correct Answer: D
Rationale: Step-by-step rationale for Answer D (Correct):
1. Safety first: Intoxicated patients can be a safety risk to themselves and others.
2. Ethical responsibility: Providing care to an intoxicated patient may compromise the quality of care.
3. Setting boundaries: Communicating that the appointment cannot proceed due to intoxication sets a clear boundary.
4. Referral assistance: The patient can be directed to appropriate resources for help with substance abuse.
Summary of why other choices are incorrect:
A (explore reasons): Not appropriate when patient is intoxicated. B (inpatient unit): Premature without assessing the situation. C (detox unit): Immediate detox may not be necessary.
A parent is admitted to a chemical dependency treatment unit. The patients spouse and adolescent children attend a family session. Which initial assessment question should the nurse ask of family members?
- A. What changes are most important to you?
- B. How are feelings expressed in your family?
- C. What types of family education would benefit your family?
- D. Can you identify a long-term goal for improved functioning?
Correct Answer: B
Rationale: It is important to understand family characteristics, particularly in a family under stress. Expression of feelings is an important aspect of assessment of the familys function (or dysfunction). The distracters relate more to outcome identification and planning interventions, both of which should be delayed until the assessment is complete.
When assessing a patient who has ingested flunitrazepam (Rohypnol), the nurse would expect:
- A. acrophobia
- B. hypothermia
- C. hallucinations
- D. anterograde amnesia
Correct Answer: D
Rationale: The correct answer is D: anterograde amnesia. Flunitrazepam is a benzodiazepine known for causing memory loss, specifically anterograde amnesia, where the person has difficulty forming new memories after ingestion. This is due to the drug's effects on the hippocampus and frontal cortex. Acrophobia (fear of heights), hypothermia, and hallucinations are not typically associated with flunitrazepam ingestion. Therefore, D is the expected outcome when assessing a patient who has ingested flunitrazepam.