Nokea
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.
You may also like to solve these questions
While caring for a family, the nurse determines that first-order changes have occurred with which of the following?
- A. The children are all in school, and the parent returns to work.
- B. The daughter leaves home to attend college.
- C. The son marries his long-time sweetheart and moves into his own home.
- D. The grandmother who has been living in the household dies.
Correct Answer: A
Rationale: The correct answer is A because first-order changes refer to small, incremental adjustments within the system. In this scenario, the parent returning to work while the children are all in school signifies a gradual shift in the family dynamic. The other choices involve significant and more disruptive changes like a daughter leaving for college, a son getting married and moving out, and the death of a family member, which are considered second-order changes that lead to more substantial shifts in the family system.
A psychiatric-mental health nurse is teaching a class about social factors associated with mental illness at a community health center. When describing the influence of poverty and effects of the downward economic spiral on mental health, which population would the nurse identify as being the most at risk?
- A. Older adults
- B. Individuals with physical disabilities
- C. Single-parent families
- D. Homeless individuals
Correct Answer: D
Rationale: The correct answer is D: Homeless individuals. Homeless individuals are the most at risk due to the severe impact of poverty and the downward economic spiral on their mental health. Homelessness often results from poverty, leading to chronic stress, lack of access to basic needs, social isolation, and increased vulnerability to mental health issues. Homeless individuals face multiple stressors that can exacerbate existing mental health conditions or lead to the development of new ones. Older adults (A) may face financial challenges but are not necessarily homeless. Individuals with physical disabilities (B) may encounter economic difficulties but are not automatically homeless. Single-parent families (C) may struggle financially, but homelessness is not exclusive to this group.
A nurse who has worked with a client diagnosed with generalized anxiety disorder (GAD) when he was an inpatient on the psychiatric unit sees the client in the waiting room of the outpatient psychiatric clinic. The client motions to the nurse to come over so he can tell the nurse how things have been going since he was discharged. While talking with the client, the nurse determines that the client's therapy has been effective when the client states which of the following?
- A. I am still experiencing quite a bit of stress at home and at work; things are different at home than they were in the hospital.
- B. When my mother-in-law comes over now, I go out to my workshop and work on one of my projects.
- C. I'm still drinking coffee; I can't quit after drinking it all these years.
- D. I've learned having a beer after I get home from work helps me relax.
Correct Answer: B
Rationale: The correct answer is B because the client's behavior of going to the workshop to work on projects when his mother-in-law visits indicates a healthy coping mechanism to manage stress. This shows that the therapy has been effective in helping the client find a constructive way to deal with his anxiety triggers. Choice A indicates ongoing stress, which suggests therapy may not be effective. Choice C shows a habit that has not changed, indicating little progress. Choice D suggests the use of alcohol as a coping mechanism, which is not a healthy or sustainable way to manage anxiety.
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.
Which statement by a patient would lead the nurse to suspect unsuccessful completion of the psychosocial developmental task of infancy?
- A. I know how to do things right, so I prefer jobs where I work alone rather than on a team.'
- B. I do not allow other people to truly get to know me.'
- C. I depend on frequent praise from others to feel good about myself.'
- D. I usually need to do things several times before I get them right.'
Correct Answer: C
Rationale: The correct answer is C because depending on frequent praise from others to feel good about oneself indicates a lack of self-confidence and self-esteem, which are key components of successful completion of the psychosocial developmental task of infancy according to Erikson's theory. This statement suggests an inability to develop a sense of autonomy and self-reliance, which are crucial in the infancy stage.
Choice A is incorrect because preferring to work alone rather than on a team may indicate a preference for autonomy, which is a positive trait related to the successful completion of the task of autonomy vs. shame and doubt in infancy.
Choice B is incorrect because not allowing others to truly get to know oneself could indicate introversion or privacy preferences, which may not necessarily suggest unsuccessful completion of the infancy developmental task.
Choice D is incorrect because needing to do things several times before getting them right may indicate a learning style or perfectionism rather than a sign of unsuccessful completion of the psychosocial developmental task of infancy.