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Based on assessment data, the nurse formulates the nursing diagnosis for a patient as sleep pattern disturbance. After teaching the patient how to relax before bedtime, the nurse determines that the teaching was effective by which outcome?
- A. Discusses feelings about not being able to fall asleep
- B. Reports feeling rested on awakening in the morning within 3 days
- C. Requests sleeping medication each night before bedtime
- D. Is able to sleep for short intervals throughout the night
Correct Answer: B
Rationale: The correct answer is B because feeling rested upon awakening indicates improved sleep quality, reflecting effective teaching on relaxation techniques. Choice A does not directly measure the effectiveness of the teaching intervention. Choice C indicates reliance on medication rather than improved sleep hygiene. Choice D, sleeping for short intervals, does not necessarily signify improved sleep quality.
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A patient has come to the clinic to discuss the stress she is experiencing because of failing two exams at school. Initially, she described her failures as 'the worst thing that has ever happened to me,' and she stated, 'There is absolutely nothing I can do to pass this course now.' In response to the nurse's questions, the nurse finds out there are three more equally weighted exams scheduled for the course in question. The nurse and patient collaborate and decide to use interventions to facilitate emotion-focused coping. Which additional comment from the patient would the nurse identify as providing support for this decision?
- A. You've got to figure out something for me to do to get me out of this situation!
- B. This is a waste of time because absolutely nothing you or I can do will make it any better.
- C. I overreacted; surely together we can figure out something for me to do.
- D. This is the worst thing that could ever happen to me. I'm nothing but a failure.
Correct Answer: C
Rationale: The correct answer is C because the patient's statement shows a shift in perspective from hopelessness to a willingness to collaborate and problem-solve. By acknowledging the possibility of working together to find a solution, the patient demonstrates openness to coping strategies. Choice A displays frustration without a willingness to participate actively. Choice B reinforces hopelessness and a defeatist attitude. Choice D reinforces negative self-perception without any indication of openness to change. In summary, choice C aligns with emotion-focused coping by showing a willingness to explore solutions collaboratively.
A client with a long history of alcohol use disorder has been diagnosed with Wernicke-Korsakoff syndrome. With which member of the mental health-care team would the nurse collaborate to meet this client's described need?
- A. The psychiatrist to obtain an order for neurocognitive disorder medications.
- B. The psychologist to set up counseling sessions to explore stressors.
- C. The dietitian to help the client increase consumption of thiamine-rich foods.
- D. The social worker to plan transportation to Alcoholics Anonymous.
Correct Answer: C
Rationale: The correct answer is C: The dietitian to help the client increase consumption of thiamine-rich foods. Wernicke-Korsakoff syndrome is caused by thiamine deficiency, commonly seen in individuals with alcohol use disorder. Thiamine supplementation is essential in managing this condition. Collaborating with a dietitian can ensure the client receives proper education and guidance on increasing thiamine intake through diet.
Incorrect choices:
A: The psychiatrist for neurocognitive disorder medications - While medications may be prescribed for symptoms, addressing the underlying thiamine deficiency is crucial.
B: The psychologist for counseling sessions - Counseling can be beneficial, but addressing the nutritional deficiency is a priority.
D: The social worker for transportation to AA - Important for ongoing support, but addressing the nutritional needs comes first to manage Wernicke-Korsakoff syndrome.
A client diagnosed with complex somatic symptom disorder and depression is prescribed medication therapy to treat both the pain and the symptoms of depression. When teaching the client about the medication, which of the following would the nurse emphasize?
- A. Need for signing a no-suicide contract
- B. Avoidance of foods that contain aged cheese
- C. Use of sunscreen when exposed to bright sunlight
- D. Limiting of the amount of water ingested
Correct Answer: B
Rationale: The correct answer is B: Avoidance of foods that contain aged cheese. Aged cheese contains tyramine, which can interact with certain medications used to treat depression, such as MAOIs. This interaction can lead to a dangerous increase in blood pressure known as a hypertensive crisis. Therefore, it is crucial for the client to avoid foods high in tyramine, such as aged cheese, to prevent this potentially life-threatening reaction. Signing a no-suicide contract (choice A) is important but not directly related to medication teaching. Using sunscreen (choice C) and limiting water intake (choice D) are not relevant considerations for this medication regimen.
When alprazolam is prescribed for a patient who experiences acute anxiety, health teaching should include instructions to
- A. report drowsiness.
- B. eat a tyramine-free diet.
- C. avoid alcoholic beverages.
- D. adjust dose and frequency based on anxiety level.
Correct Answer: C
Rationale: The correct answer is C: avoid alcoholic beverages. This is because alprazolam is a central nervous system depressant, and alcohol also has depressant effects. Combining the two can potentiate sedation and respiratory depression. Reporting drowsiness (A) is important but not specific to alprazolam. Eating a tyramine-free diet (B) is relevant for certain medications like MAOIs, not alprazolam. Adjusting dose and frequency based on anxiety level (D) is not recommended as it can lead to misuse or dependence.
A client with signs and symptoms of double pneumonia states,"I will not agree to hospital admission unless my shaman is allowed to continue helping me." Which would be an appropriate nursing intervention?
- A. Tell the client that the shaman is not allowed in the emergency department.
- B. Have the shaman meet the attending physician at the hospital.
- C. Have the family talk the client into admission without the shaman.
- D. Explain to the client that the shaman is responsible for the client's condition.
Correct Answer: B
Rationale: The correct answer is B. Having the shaman meet the attending physician at the hospital is the most appropriate nursing intervention because it allows for collaboration between traditional beliefs and modern medical care. This approach respects the client's cultural and spiritual preferences while ensuring the client receives necessary medical treatment. It also helps establish a supportive and holistic care environment.
Choice A is incorrect because denying the shaman access may lead to resistance from the client and hinder effective communication and trust-building. Choice C is inappropriate as it disregards the client's autonomy and may create conflict within the family. Choice D is incorrect as blaming the shaman for the client's condition is disrespectful and unprofessional.