Nokea
During morning care, the nursing assistant asks a patient with dementia, 'How was your night?' The patient replies, 'It was lovely. My husband and I went out to dinner and to a movie.' The nurse who overhears this should make the assessment that the patient is:
- A. Demonstrating a sense of humor.
- B. Using confabulation.
- C. Perseverating.
- D. None of the above.
Correct Answer: B
Rationale: The correct answer is B: Using confabulation. Confabulation is when a person with dementia unknowingly creates fictitious memories to fill in gaps in their memory. In this scenario, the patient's response of going out to dinner and a movie with their husband is not based in reality, indicating confabulation. A: Demonstrating a sense of humor is incorrect because the patient is not intentionally being humorous. C: Perseverating is incorrect as it refers to repeating the same words or phrases, which is not evident in the patient's response. D: None of the above is incorrect as the patient's response aligns with confabulation.
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When a nurse overhears the spouse of a patient threaten to 'smack you good if you don't shut up' while sitting in the unit's dayroom, which action reflects the most immediate, therapeutic nursing intervention?
- A. Notify hospital security immediately that the situation exists!
- B. Tell the spouse, 'Your presence is no longer permitted on the unit.'
- C. Ask the patient if the spouse has ever engaged in physically abusive behavior.
- D. Tell the spouse, 'The police will be called unless you leave immediately.'
Correct Answer: A
Rationale: The correct answer is A: Notify hospital security immediately that the situation exists. This is the most immediate, therapeutic nursing intervention because the safety of the nurse, patient, and others in the unit is the top priority. By involving hospital security, the nurse can ensure a swift and appropriate response to the threatening behavior. This action helps to de-escalate the situation and protect everyone involved.
The other choices are incorrect because:
B: Asking the spouse to leave the unit could escalate the situation further and put the nurse at risk.
C: Asking the patient about the spouse's behavior may not be immediate enough to address the threat.
D: Threatening to call the police could escalate the situation and may not be the best approach to ensure safety for all parties involved.
When a victim of sexual assault is discharged from the emergency department, the nurse should:
- A. Notify the patient's family of the event to ensure support for the patient.
- B. Offer to stay with the patient until stability is regained.
- C. Advise the patient to try not to think about the assault.
- D. Provide referral information verbally and in writing.
Correct Answer: D
Rationale: The correct answer is D because providing referral information verbally and in writing ensures that the victim has access to appropriate resources for follow-up care and support. This step is crucial in helping the victim navigate the emotional and physical aftermath of the assault.
A: Notifying the patient's family without the patient's consent could violate the patient's privacy and autonomy.
B: While offering to stay with the patient shows support, it may not always be feasible and may not address the victim's long-term needs.
C: Advising the patient to try not to think about the assault is dismissive of their trauma and does not provide constructive support.
A patient moving from chair to chair in the day room and pacing in the hallway repeatedly, rapidly, and for extended periods is likely demonstrating ______, and the nurse should ______.
- A. a dystonic reaction"¦administer PRN IM benztropine (Cogentin)
- B. anxiety"¦ teach and guide the patient to use relaxation exercises
- C. akathisia"¦administer PRN diphenhydramine (Benadryl) PO
- D. tardive dyskinesia"¦recommend a change in medication
Correct Answer: C
Rationale: The correct answer is C: akathisia"¦administer PRN diphenhydramine (Benadryl) PO. Akathisia is characterized by restlessness and an inability to sit still. Administering diphenhydramine can help alleviate these symptoms. A is incorrect because dystonic reactions present with muscle spasms and abnormal postures, not restlessness. B is incorrect as anxiety does not typically manifest as physical restlessness. D is incorrect as tardive dyskinesia involves involuntary movements of the face and body, not restlessness.
When undertaking care for a patient with an eating disorder, a nurse should first:
- A. perform a complete patient assessment.
- B. obtain a history from the patient's family.
- C. examine his or her own feelings about weight.
- D. question the patient as to when he or she last ate a meal.
Correct Answer: C
Rationale: The correct answer is C because examining the nurse's own feelings about weight is essential to ensure they have a neutral and non-judgmental attitude towards the patient. This self-awareness helps the nurse avoid projecting biases onto the patient and fosters a therapeutic relationship. Performing a complete patient assessment (A) is important but not the first step. Obtaining a history from the patient's family (B) may be helpful but is not the initial priority. Questioning the patient about their last meal (D) is important but does not address the nurse's own attitudes and biases that could impact care.
A 10-year-old boy presents with a history of central abdominal pain of a few hours' duration. On examination he has minimal tenderness in the right iliac fossa and no abnormal findings on rectal examination. Which of the following alternatives should be carried out?
- A. Arrange a barium meal follow through.
- B. Arrange to see the patient later on in the day for review.
- C. Send the patient away with instructions to return if the pain becomes worse.
- D. Tell the patient to come back in a week.
Correct Answer: B
Rationale: Early appendicitis can present subtly. Minimal right iliac fossa tenderness warrants observation, so reviewing later (B) is appropriate. Imaging (A), dismissal (C, D), or immediate surgery (E) without further assessment are not justified yet.