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Which intervention will the nurse implement in the first half hour after the patient has received ECT?
- A. Continually stimulate patient to respond, using physical and verbal means.
- B. Continue bagging patient to improve respiratory function until patient is responsive for 10 minutes.
- C. Reorient as necessary to time, place, and person as level of consciousness improves.
- D. Encourage walking and eating breakfast as quickly as possible.
Correct Answer: C
Rationale: The correct answer is C because reorienting the patient to time, place, and person is crucial in the immediate post-ECT period to help the patient regain orientation as consciousness improves. This intervention helps prevent confusion and disorientation commonly experienced after ECT. A: Continually stimulating the patient may be overwhelming and unnecessary. B: Continuing bagging is not relevant after ECT as the patient's respiratory function should have stabilized. D: Encouraging walking and eating can be unsafe immediately post-ECT due to potential disorientation and muscle weakness.
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Which developmental level would be characterized by a child being able to focus, coordinate, and imagine a series of events?
.
- A. Preoperational
- B. Concrete operational
- C. Formal operational
- D. Postoperational
Correct Answer: B
Rationale: The correct answer is B: Concrete operational. At this developmental level, children typically exhibit the ability to focus, coordinate, and imagine a series of events. This stage, according to Piaget's theory, usually occurs around ages 7 to 11. Children at this stage can perform logical operations, understand conservation, and think more systematically.
A: Preoperational - Children at this stage (ages 2-7) lack the ability to perform logical operations and struggle with understanding conservation and cause-and-effect relationships.
C: Formal operational - This stage (typically starting around age 11) involves abstract thinking, hypothetical reasoning, and problem-solving beyond the concrete level.
D: Postoperational - This term is not a recognized developmental stage in Piaget's theory.
When making a distinction as to whether an elderly patient has confusion related to delirium or another problem, what information would be of particular value?
- A. Evidence of spasticity or flaccidity
- B. Medications the patient has recently taken.
- C. Level of preoccupation with somatic symptoms
- D. The patient’s level of motor activity
Correct Answer: B
Rationale: The correct answer is B: Medications the patient has recently taken. This is crucial because certain medications can cause delirium in elderly patients. Step 1: Evaluate recent medication history. Step 2: Identify medications known to cause delirium. Step 3: Determine if the patient has taken any of these medications. Other choices are incorrect because: A: Evidence of spasticity or flaccidity is more related to neuromuscular conditions. C: Level of preoccupation with somatic symptoms is not specific to delirium assessment. D: The patient’s level of motor activity is not a key factor in distinguishing delirium from other problems.
Which patient would the group co-leaders determine is demonstrating Yalom’s therapeutic factor termed universality?
- A. Patient A, who states he realizes he is not the only person who has a problem with loneliness
- B. Patient B, who displays dysfunctional interaction patterns learned in his family of origin
- C. Patient C, who states he finally feels a strong sense of belonging
- D. Patient D, who openly expresses his anger about his work
Correct Answer: A
Rationale: The correct answer is A because universality in Yalom's therapeutic factors refers to the recognition that one is not alone in their struggles. Patient A demonstrates this by acknowledging that others also face loneliness, fostering a sense of commonality and reducing feelings of isolation. In contrast, patient B's dysfunctional patterns do not relate to universality. Patient C's sense of belonging is related to group cohesion, not universality. Patient D's anger expression is not directly linked to recognizing shared experiences.
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.
Family and friends rush to offer support to a friend who has lost her teenage son. Which of these persons, through an intended act of kindness, may contribute to prolonging the woman’s grief?
- A. The physician who prescribed antianxiety agents
- B. The nurse who offered to spend the night at her home
- C. The next-door teenager who provided care for the son’s pet
- D. The accountant who assisted with stabilizing financial affairs.
Correct Answer: A
Rationale: The correct answer is A because prescribing antianxiety agents may mask the woman's grief instead of allowing her to process and work through it naturally. This could potentially prolong her grief by avoiding the necessary emotional processing. The other choices, B, C, and D, all involve support that can help the woman cope with her loss in a healthy way. B offers emotional support and companionship, C helps with practical tasks, and D provides assistance in managing practical matters, all of which can facilitate the grieving process rather than prolong it.