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By discharge, which outcome is appropriate for a patient who hears voices telling them they are evil?
- A. Respond verbally to the voices.
- B. Verbalize the reason the voices say they are evil
- C. Identify events that increase anxiety and promote hallucinations.
- D. Integrate the voices into their personality structure in a positive manner.
Correct Answer: C
Rationale: Identifying triggers for hallucinations is a key step in managing symptoms effectively
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In a sad voice, an elderly patient tells the nurse of the recent deaths of a spouse and close friend. The patient has no other family and only a few acquaintances in the community. The nurse’s priority is to determine whether which nursing diagnosis applies to this patient?
- A. Risk for suicide related to recent deaths of significant others.
- B. Anxiety related to sudden and abrupt lifestyle changes.
- C. Social isolation related to loss of existing family
- D. Spiritual distress related to anger with God.
Correct Answer: A
Rationale: The patient’s sadness and recent significant losses (spouse and friend) put them at risk for depression and suicidal ideation. The nurse should assess for suicidal thoughts and behaviors.
A patient is experiencing distress with midlife transition. Which statement provides support that the patient is successfully managing this stressor?
- A. “I won’t give up on my dream to be rich.”
- B. “I wasn’t being realistic when I set being rich as my life’s goal.”
- C. “I’ll never be rich, but I can save enough to live comfortably.”
- D. “Being rich doesn’t necessarily make a person happy.”
Correct Answer: C
Rationale: Successfully managing midlife transitions involves finding realistic and satisfying alternatives to earlier, unmet goals, demonstrating emotional growth and adaptability.
A patient is being seen for symptoms of insomnia and significant weight loss that has occurred during the 2 months since her husband’s death. What is the purpose of the query, “Describe how it has been for you since your husband died?”
- A. To display an attitude of concern and sympathy to the patient
- B. To learn whether the patient has a significant support system
- C. To rule out factors that may interfere with diagnosing her illness
- D. To determine the risk for pathologic grief and the need for grief therapy
Correct Answer: D
Rationale: The purpose of the query "Describe how it has been for you since your husband died?" is to determine the risk for pathologic grief and the need for grief therapy. The patient is experiencing symptoms of insomnia and significant weight loss following her husband's death, which could indicate complicated or pathologic grief. By asking this open-ended question, the healthcare provider can gain insight into the patient's emotional well-being, coping mechanisms, and overall adjustment to the loss. The response can help assess whether the patient might benefit from additional support or interventions, such as grief therapy, to help her navigate through the grieving process in a healthy manner. It is essential to identify and address any potential complications related to grieving to provide appropriate care and support to the patient.
In the ECT treatment preparation period the morning of treatment, the nurse should:
- A. Assess the patient’s cognitive function.
- B. Have the patient exercise for 10 minutes.
- C. Ensure that the patient produces a urine sample.
- D. Allow the patient to eat a heavy meal if they are hungry.
Correct Answer: A
Rationale: The correct action during the ECT treatment preparation period the morning of treatment is to adequately hydrate the patient. Ensuring that the patient is properly hydrated before the procedure is crucial for their safety and well-being. Hydration helps optimize the effects of the treatment and can support the patient's recovery post-treatment. It is important to maintain the patient's fluid balance as ECT can sometimes cause side effects such as nausea, headache, and muscle aches, which can be worsened if the patient is not adequately hydrated. Additionally, hydration can help prevent complications such as dehydration or electrolyte imbalances during and after the ECT procedure.
Which statement best explains how a mother of several children should prepare to help them cope with the loss of a dear aunt?
- A. Children are resilient and simply need love as they grieve.
- B. People regardless of age or gender experience stages of grief.
- C. Each child will grieve in a unique way and on their own timetable
- D. .Extreme reactions are more commonly observed in the young griever.
Correct Answer: C
Rationale: Each child will grieve in a unique way and on their own timetable. It is essential for the mother to acknowledge and understand that each of her children will process the loss of their dear aunt differently. Some children might show their emotions openly and seek comfort, while others might prefer to process their feelings more privately. By recognizing and respecting these individual differences, the mother can provide the necessary support tailored to each child's specific needs. This approach helps create a supportive environment where each child feels understood and cared for as they navigate their grief journey.