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During the first family therapy session, the mother of a child being treated for truancy and emotional outbursts asks the nurse, “Why are you bothering to ask the rest of us questions? My son is the one with the problems.” The best response for the nurse would be:
- A. “We’ll get more accurate information if the entire family is involved.”
- B. “It may seem strange to you, but we’ll get better results doing it this way.”
- C. “When one family member is sick, the whole family system is sick as well.”
- D. “Every family member’s perceptions are very important to the total picture.”
Correct Answer: A
Rationale: The correct answer is A because involving the entire family in therapy sessions allows for a more comprehensive understanding of the family dynamics and how they may be contributing to the child's issues. By including all family members, the nurse can gather diverse perspectives and insights that can inform the treatment plan. This approach also promotes family unity and collaboration in addressing the child's problems.
Option B is not the best response as it lacks a clear rationale for involving the whole family. Option C, while partially true, does not directly address the question raised by the mother. Option D emphasizes the importance of every family member's perceptions but does not specifically address the benefits of involving the entire family in therapy sessions.
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About an hour after the patient has ECT, he complains of having a headache. The nurse should:
- A. Notify the physician stat.
- B. Administer an as needed (prn) dose of acetaminophen.
- C. Take the patient through a progressive relaxation sequence.
- D. Advise going to activities to expend energy and relieve tension.
Correct Answer: B
Rationale: The correct answer is B: Administer an as needed (prn) dose of acetaminophen. After ECT, it is common for patients to experience headaches as a side effect. Administering acetaminophen will help alleviate the headache and provide relief for the patient. It is important to address the patient's discomfort promptly and effectively.
Choice A is incorrect because headaches after ECT are a common side effect and do not typically require immediate physician notification. Choice C is incorrect as progressive relaxation may not address the immediate headache symptoms. Choice D is also incorrect as physical activities may exacerbate the headache rather than provide relief. Administering acetaminophen is the most appropriate and efficient intervention in this situation.
Select the best outcome for a patient with the nursing diagnosis: "Impaired social interaction related to sociocultural dissonance as evidenced by stating, 'Although I’d like to, I don’t join in because I don’t speak the language very well.'” Patient will:
- A. Show improved use of language.
- B. Demonstrate improved social skills.
- C. Become more independent in decision-making.
- D. Select and participate in one group activity per day.
Correct Answer: D
Rationale: The correct answer is D: Select and participate in one group activity per day. This outcome directly addresses the nursing diagnosis of impaired social interaction by encouraging the patient to engage in a specific social activity daily. This goal promotes social interaction, helps the patient overcome language barriers, and gradually enhances their social skills. It provides a structured approach to improve the patient's sociocultural integration.
A: Show improved use of language - This choice focuses solely on language skills but does not directly address the social interaction issue.
B: Demonstrate improved social skills - While this choice is related to the nursing diagnosis, it is too broad and lacks specificity compared to choice D.
C: Become more independent in decision-making - This choice is not directly related to addressing impaired social interaction caused by language barriers.
A child who has been physically abused becomes emotionally distressed when told that the parent will no longer be allowed to visit. Which principle of social learning theory explains the child’s response?
- A. The child views the abuse as more desirable than the parent leaving
- B. The parent has fostered a fear in the child that increases when they are apart.
- C. The child believes they are responsible for the parent being punished.
- D.
The parent has likely told the child that they deserved the abuse as punishment.
Correct Answer: C
Rationale: The correct answer is C: The child believes they are responsible for the parent being punished. According to social learning theory, individuals learn behaviors through observation and modeling. In this scenario, the child has internalized the belief that they are the cause of the parent's punishment due to the abuse. This leads to feelings of guilt and distress when the parent is no longer allowed to visit.
A: The child does not view abuse as desirable; it is a harmful behavior.
B: While fear may be present, the core issue lies in the child's belief of responsibility.
D: The parent blaming the child for the abuse does not align with the principles of social learning theory.
During a bereavement group, one of the members states, “I should have been the one to die. My husband had so much to offer.” The member was expressing:
- A. Ambivalence and low self-esteem
- B. Unresolved anger toward her husband
- C. A need for attention from group members
- D. Depression
Correct Answer: A
Rationale: The correct answer is A: Ambivalence and low self-esteem. The member's statement reflects conflicting emotions (ambivalence) about her worth compared to her husband's. This indicates low self-esteem, as she believes she is less valuable. Unresolved anger (B) would involve blaming her husband, not herself. A need for attention (C) is not evident, as she is sharing personal feelings. Depression (D) may be present, but the statement specifically points to self-deprecation, not just a general feeling of sadness.
Which statement made by a patient just prior to being transported for a scheduled ECT treatment would result in cancellation of the treatment?
- A. “Will I remember having this treatment?”
- B. “Did eating some crackers cause any problems?”
- C. "Is this going to help me feel better soon?"
- D. "I feel like I need to ask more questions about the procedure."
Correct Answer: A
Rationale: The correct answer is A because asking about memory loss indicates a lack of informed consent and understanding of ECT procedure. Memory loss is a common side effect of ECT, and a patient should be well-informed about it before treatment. Choices B, C, and D do not raise concerns about the patient's understanding or readiness for ECT, making them incorrect. Choice B asks about dietary concerns, which do not directly impact the treatment. Choice C shows the patient's hope for improvement, which is a positive attitude. Choice D indicates the patient's desire for more information, which is a sign of engagement in their care.