Nokea
During a grief-processing group, an elderly patient stated, For the first time since my husband died, Im having more good days than bad. This statement suggests that the patient has:
- A. Replaced old memories with new ones
- B. Reached the phase of reestablishment
- C. Completed her grief work successfully
- D. Determined she is ready to terminate the support group
Correct Answer: B
Rationale: Reestablishment is a phase of grief characterized by finding balance, experiencing positive moments, and reduced intensity of sadness.
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A patient tries to gouge out their eye in response to auditory hallucinations. The nurse would analyze this behavior as indicating:
- A. Derealization
- B. Inappropriate affect
- C. Impaired impulse control
- D. Inability to manage anger
Correct Answer: C
Rationale: Self-harm in response to hallucinations reflects impaired ability to control impulses and respond safely to internal stimuli.
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.
Which statement would the nurse use to describe the primary purpose of boundaries?
- A. Boundaries define responsibilities and duties to one’s self in relation to others.
- B. Boundaries determine objectives of the various working stage of the relationship.
- C. Boundaries differentiate the assumed roles of both the nurse and of the patient.
- D. Boundaries prevent undesired material from emerging during the interaction.
Correct Answer: A
Rationale: Boundaries define responsibilities and duties to one’s self in relation to others. Setting boundaries is essential in establishing a safe and professional therapeutic relationship between a nurse and a patient. These boundaries help to create a clear understanding of each person's roles and responsibilities within the relationship. Boundaries also help protect both the nurse and the patient from potential harm, maintain professionalism, and ensure effective communication and focus on the therapeutic goals. By defining these boundaries, the nurse can better maintain appropriate relationships with patients and avoid conflicts of interest or ethical dilemmas.
According to Piaget, which of the following would the nurse consider normal when assessing a 6-year-old?
- A. Playing with an imaginary friend
- B. Talking about their best friend
- C. Enjoying putting puzzles together
- D. Knowing it’s wrong to tell a lie
Correct Answer: C
Rationale:
At 6 years old, children are typically in the concrete operational stage of development, characterized by logical thinking and enjoyment of problem-solving activities like puzzles.
Which assessment finding should be considered a high risk factor for adolescent suicide?
- A. Being sexually abused.
- B. Having experienced panic attacks
- C. Being mildly cognitively impaired
- D. Having a diagnosis of type 1 diabetes
Correct Answer: A
Rationale: Adolescents who have been sexually abused are at a higher risk for suicide. Trauma can significantly impact mental health, increasing the risk of depression, self-harm, and suicidal thoughts.