Nokea
For which behavior(s) would limit setting be most essential?
- A. A patient clings to the nurse and asks for advice about inconsequential matters.
- B. A woman is flirtatious and provocative toward staff members of the opposite sex.
- C. An elderly man displays hypervigilance and refuses to attend unit activities.
- D. A young woman urges a suspicious patient to hit anyone who stares at him.
Correct Answer: D
Rationale: The correct answer is D because it involves a behavior that is potentially harmful and puts others at risk. Setting limits is essential to prevent violence and protect both the patient and others. A: Clinging behavior is not inherently harmful. B: Flirtatious behavior, while inappropriate, does not pose a direct threat. C: Hypervigilance and refusal to attend activities may indicate underlying issues but do not require immediate limit setting for safety.
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What is the priority nursing intervention when caring for a patient with bulimia nervosa who has a history of purging?
- A. Provide emotional support and assist with stress management.
- B. Monitor vital signs and electrolyte levels closely.
- C. Encourage the patient to exercise regularly to prevent weight gain.
- D. Help the patient identify triggers for binge eating and purging behaviors.
Correct Answer: B
Rationale: The correct answer is B because monitoring vital signs and electrolyte levels closely is crucial in managing a patient with bulimia nervosa who has a history of purging. Purging can lead to electrolyte imbalances and dehydration, which can have serious consequences such as cardiac arrhythmias and electrolyte disturbances. By closely monitoring vital signs and electrolyte levels, nurses can quickly identify and intervene in case of any abnormalities, preventing potential life-threatening complications.
Choice A is incorrect because emotional support and stress management are important but not the priority when dealing with physical complications from purging. Choice C is incorrect because encouraging exercise may exacerbate the patient's unhealthy behaviors and should be approached cautiously. Choice D is incorrect because identifying triggers is important but not as immediate as monitoring vital signs and electrolyte levels in this situation.
In the OB follow-up clinic, your patient, who is 4 weeks post-delivery, tells you she is sleeping for long hours, wants to avoid taking care of the baby, and wishes she had never had the baby. What would be your first response?
- A. Its normal to feel overwhelmed at first.
- B. Tell me more about these feelings.
- C. Report her to Child Protective Services.
- D. Ill call your husband right away to get you back home to rest.
Correct Answer: B
Rationale: The open-ended question (B) will give you more information and be less judgmental to this patient. This behavior is not normal at 4 weeks post-delivery and more rest is probably not adequate treatment. You would like a lot more information before reporting this as neglect.
A young patient diagnosed with schizophrenia is standing naked after showering and appears to be both dazed and indecisive. The nursing intervention that will be most helpful to promote dressing would be:
- A. saying, 'These are your clothes. Please get dressed.'
- B. saying, 'These are your underpants. I'll help you put them on.'
- C. asking, 'Which of these two outfits would you like to wear now?'
- D. asking, 'Is something the matter with your clothes that makes you not want to dress?'
Correct Answer: B
Rationale: The correct answer is B. By saying, "These are your underpants. I'll help you put them on," the nurse provides clear guidance and offers assistance, which can help the patient feel more comfortable and supported in the dressing process. This approach acknowledges the patient's need for help while respecting their autonomy.
Choice A is too directive and may make the patient feel pressured or overwhelmed. Choice C involves too many options, which can be confusing for a patient experiencing indecisiveness. Choice D assumes a problem with the clothes rather than focusing on the patient's needs and feelings. Overall, choice B is the most appropriate and supportive intervention in this situation.
In DSM-IV-TR intellectual disabilities are divided into a number of degrees of severity, depending primarily on the range of IQ score provided by the sufferer. One of these is Moderate Mental Retardation, represented by an IQ score between:
- A. 60-65 - to 70-75
- B. 35-40 to 50-55
- C. 80-85 to 90-95
- D. 20-25 to 30-35
Correct Answer: B
Rationale: Moderate Mental Retardation: Defined by DSM-IV-TR as an IQ score between 35-40 to 50-55.
A depressed patient who is taking a tricyclic antidepressant tells the nurse, "I don't think I can keep taking these pills. They make me very dizzy, especially when I stand up." The best nursing response is:
- A. That is annoying, but it is something most patients are able to learn to live with as time goes on. You'll get used to the medicine's side effects.
- B. The medicine can slow the body's adjustment of blood pressure when changing position; drinking more fluids and changing position slowly can help.
- C. Compared to the problems caused by the depression, it seems like a relatively small annoyance to have to put up with.
- D. All medicines have side effects, and this one is relatively mild. It could be that your depression is causing you to think negatively about the medicine.
Correct Answer: B
Rationale: The correct answer is B because tricyclic antidepressants can cause orthostatic hypotension leading to dizziness upon standing. Advising the patient to drink more fluids and change positions slowly can help alleviate this symptom. Choice A minimizes the patient's concern, which is not therapeutic. Choice C diminishes the patient's experience and feelings. Choice D dismisses the patient's symptoms and attributes them solely to the patient's negative thinking, which is not appropriate.