Nokea
Before assessing a new patient, a nurse is told by another health care worker, "I know that patient. No matter how hard we work, there isn’t much improvement by the time of discharge." The nurse’s responsibility is to:
- A. Document the other worker’s assessment of the patient.
- B. Assess the patient based on data collected from all sources.
- C. Validate the worker’s impression by contacting the patient’s significant other.
- D. Discuss the worker’s impression with the patient during the assessment interview.
Correct Answer: B
Rationale: A nurse should maintain objectivity and conduct their own assessment, considering all sources of information.
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An elderly patient brings a bag of medications to the clinic. The nurse finds a bottle labeled Ativan and one labeled lorazepam, both of which are to be taken BID. There are also bottles labeled hydrochlorothiazide, Inderal, and rofecoxib, each to be taken once daily. Which conclusion is accurate?
- A. Rofecoxib should not be taken with Ativan
- B. Lorazepam and Ativan are the same drug, so the dose is excessive.
- C. Lorazepam interferes with the action of Inderal.
- D. The patient should not self-administer medication.
Correct Answer: B
Rationale: Ativan and lorazepam are the same drug, so the patient is taking an excessive dose of lorazepam. This requires intervention by the nurse to prevent harm.
A nurse, leading an inpatient group dealing with women’s issues, identifies a patient who is assuming the role of aggressor. Which behavior characterizes this role?
- A. Mediating conflicts and disagreements
- B. Criticizing the contributions of others
- C. Seeking a position between contending sides
- D. Remaining quiet and refraining from participating in group discussions
Correct Answer: B
Rationale: In a group setting, a patient assuming the role of aggressor typically exhibits behaviors such as criticizing the contributions of others, being hostile, confrontational, and attempting to assert dominance. This behavior can create a negative and hostile environment in the group, undermining the therapeutic process. It is important for the nurse to recognize and address this behavior in order to promote a safe and supportive atmosphere for all group members to participate and benefit from the sessions.
An elderly patient must be physically restrained. Who is responsible for the patient's safety?
- A. Unlicensed assistive personnel who apply the restraint
- B. Family member who agrees to the application of the restraint
- C. The nurse assigned to care for the patient.
- D. Health care provider who prescribed the application of restraint
Correct Answer: C
Rationale: The nurse is responsible for the patient’s safety, including the appropriate use of restraints and ensuring the patient is monitored appropriately. The nurse is accountable for assessing the need for restraints, their proper application, and ongoing evaluation of the patient’s condition while restrained
Which intervention will the nurse planning care for a patient with acute grief implement?
- A. Encouraging dependence on the nurse for support
- B. Providing information about the grief process
- C. Suggesting utilization of community resources in a few weeks
- D. Advising the patient to minimize contact with nonfamily members
Correct Answer: B
Rationale: Providing information about grief is an important intervention for individuals experiencing acute grief. It helps the patient understand their emotional reactions and the natural process of grieving, reducing feelings of isolation or confusion.
What milieu factor would need most attention from the nurse who is caring for a patient who has received six ECT treatments and has two more sc\
- A. Therapeutic activities
- B. Boundary maintenance
- C. Safety
- D. Trust attainment
Correct Answer: C
Rationale: When caring for a patient who has received multiple electroconvulsive therapy (ECT) treatments and has more scheduled, the most critical milieu factor that needs attention is safety. ECT is a medical procedure that involves inducing seizures through electrical stimulation, and patients may be at risk of physical harm during or after the treatments. The nurse should prioritize ensuring the patient's safety during and after the ECT sessions, including monitoring for any adverse effects, providing support, and taking necessary precautions to prevent accidents. Safety measures, such as fall prevention protocols and close observation, are essential in the care of patients undergoing ECT to ensure their well-being. Therefore, safety is the milieu factor that requires the most attention in this situation.