Nokea
By the end of the orientation phase, which outcome can be identified for a newly admittedpatient? The patient will demonstrate:
- A. Positive transference with a staff member
- B. Ability to ask for help in meeting needs
- C. Commitment to long-term therapy
- D. Ability to manage symptoms independently
Correct Answer: A
Rationale: The correct answer is A because positive transference with a staff member in the orientation phase indicates a developing therapeutic relationship, which is crucial for effective treatment. This outcome shows the patient is beginning to trust and feel safe with a staff member, enhancing their engagement in therapy.
Choice B is incorrect because the ability to ask for help in meeting needs may not be fully developed by the end of the orientation phase. Choice C is incorrect as commitment to long-term therapy is usually not established this early in the process. Choice D is incorrect because the ability to manage symptoms independently typically requires more time and therapy progress.
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A nurse assesses four patients between the ages of 70 and 80. Which patient has the highest risk for alcohol abuse? The patient who:
- A. Consumes 1 glass of wine nightly with dinner.
- B. Drank socially throughout adult life and continues this pattern, saying, “I’ve earned the right to do as I please.”
- C. Began drinking alcohol daily after retirement and says, “A few drinks keep my mind off my arthritis.”
- D. Abused alcohol between the ages of 25 and 40 but now abstains and occasionally attends Alcoholics Anonymous (AA).
Correct Answer: C
Rationale: The correct answer is C because the patient who started drinking daily after retirement as a coping mechanism for arthritis has the highest risk for alcohol abuse. This behavior indicates a potential dependence on alcohol to manage physical and emotional discomfort, leading to increased consumption and potential addiction.
Choice A is not the correct answer because consuming 1 glass of wine nightly with dinner is generally considered moderate drinking and does not necessarily indicate alcohol abuse.
Choice B is also not the correct answer as social drinking throughout adult life, even if justified as a reward, does not inherently suggest alcohol abuse without further evidence of problematic drinking patterns.
Choice D is incorrect as the patient has a history of alcohol abuse but currently abstains and seeks support through AA, indicating active efforts to maintain sobriety and reduce the risk of alcohol abuse.
What is the priority nursing diagnosis for a catatonic patient?
- A. Ineffective coping
- B. Impaired physical mobility
- C. Risk for deficient fluid volume
- D. Impaired social interaction
Correct Answer: C
Rationale: The priority nursing diagnosis for a catatonic patient is Risk for deficient fluid volume (C) because catatonic patients are at risk for dehydration due to decreased fluid intake or inability to meet fluid needs. This diagnosis takes precedence over others as dehydration can lead to serious complications. Ineffective coping (A) may be secondary to the catatonic state but addressing fluid volume is more urgent. Impaired physical mobility (B) and Impaired social interaction (D) are important but not as critical as addressing the risk of dehydration in a catatonic patient.
An outcome for a patient experiencing anticipatory grieving for a spouse diagnosed with terminal cancer would be that the patient will:
- A. Continue to be emotionally involved with the dying spouse
- B. Develop protective mental mechanisms to allay the pain of spousal loss
- C. Not voice threats of physical violence that is either self or others directed
- D. Agree to stay at home and care for the spouse with appropriate assistance
Correct Answer: A
Rationale: The correct answer is A because anticipatory grieving involves emotional involvement with the dying spouse. This allows the patient to process emotions, express love, and make meaningful connections before the actual loss. Choice B is incorrect as it suggests avoidance of pain through mental mechanisms, which is not conducive to healthy grieving. Choice C is incorrect as it focuses on a specific behavior (violence) rather than the emotional process of grieving. Choice D is incorrect as it assumes the patient's agreement to care for the spouse is the primary outcome, overlooking the emotional aspect of anticipatory grief.
The common element seen in every type of bereavement is:
- A. Bereavement is a predictable process that is a result of loss.
- B. The individual has experienced the loss of something of importance.
- C. Acute depression is generally experienced by all who grieve for a loss.
- D. Yearning or longing for the deceased
Correct Answer: B
Rationale: The correct answer is B because it captures the essence of bereavement - the experience of loss. This choice acknowledges that bereavement involves losing something significant, which is a universal aspect of grieving. Other choices are incorrect - A is not always predictable, C is not always acute depression, and D focuses on a specific aspect of grief rather than the core element of loss. Therefore, B is the most comprehensive and inclusive choice.
Planning safety interventions for a teenager with a history of self-injurious behavior is based on what research-based information?
- A. Teenagers rarely entertain the idea of suicide.
- B. Self-injury is always viewed as a risk factor for future suicidal attempts.
- C. Assessment for suicidal ideations is a vital component of this child's care.
- D. Suicides can occur accidentally as a result of self-injurious behaviors.
Correct Answer: D
Rationale: The correct answer is D because research indicates that suicides can occur accidentally as a result of self-injurious behaviors. This is known as an unintentional suicide, where the individual did not intend to die but died due to the severity of their self-injurious behavior. This information is crucial for planning safety interventions for the teenager, as it highlights the potential seriousness of self-injury.
Choice A is incorrect because research shows that suicidal ideation is not uncommon among teenagers, so it cannot be assumed that they rarely entertain the idea of suicide. Choice B is also incorrect because while self-injury can be a risk factor for future suicidal attempts, it is not always the case. Choice C is relevant but not the most specific to the scenario presented in the question, as it focuses solely on suicidal ideations rather than the potential accidental outcomes of self-injury.