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In a sad voice, an elderly patient tells the nurse of the recent deaths of a spouse and close friend. The patient has no other family and only a few acquaintances in the community. The nurse’s priority is to determine whether which nursing diagnosis applies to this patient?
- A. Risk for suicide related to recent deaths of significant others.
- B. Anxiety related to sudden and abrupt lifestyle changes.
- C. Social isolation related to loss of existing family
- D. Spiritual distress related to anger with God.
Correct Answer: A
Rationale: The patient’s sadness and recent significant losses (spouse and friend) put them at risk for depression and suicidal ideation. The nurse should assess for suicidal thoughts and behaviors.
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A patient is experiencing distress with midlife transition. Which statement provides support that the patient is successfully managing this stressor?
- A. “I won’t give up on my dream to be rich.”
- B. “I wasn’t being realistic when I set being rich as my life’s goal.”
- C. “I’ll never be rich, but I can save enough to live comfortably.”
- D. “Being rich doesn’t necessarily make a person happy.”
Correct Answer: C
Rationale: Successfully managing midlife transitions involves finding realistic and satisfying alternatives to earlier, unmet goals, demonstrating emotional growth and adaptability.
Which activity therapy should the nurse recommend to the treatment team to assist the patient to relieve tension and achieve increased body awareness?
- A. Music therapy
- B. Dance therapy
- C. Recreation
- D. Relaxation exercises
Correct Answer: B
Rationale: Dance therapy is a form of activity therapy that uses movement and dance to promote emotional, social, cognitive, and physical integration and well-being. It can help individuals relieve tension, connect with their bodies, and increase body awareness. Through dancing, patients can release emotions, express themselves non-verbally, and improve their overall sense of well-being. Additionally, dance therapy can also help improve muscle tone, coordination, and flexibility, thereby contributing to physical health. Overall, dance therapy can be a beneficial intervention to assist the patient in relieving tension and achieving increased body awareness.
Before assessing a new patient, a nurse is told by another health care worker, "I know that patient. No matter how hard we work, there isn’t much improvement by the time of discharge." The nurse’s responsibility is to:
- A. Document the other worker’s assessment of the patient.
- B. Assess the patient based on data collected from all sources.
- C. Validate the worker’s impression by contacting the patient’s significant other.
- D. Discuss the worker’s impression with the patient during the assessment interview.
Correct Answer: B
Rationale: A nurse should maintain objectivity and conduct their own assessment, considering all sources of information.
What would be an appropriate short-term outcome for a patient diagnosed with residual schizophrenia who exhibits ambivalence?
- A. Decide their own daily schedule.
- B. Decide which unit groups they will attend.
- C. Choose between two outfits to wear each morning.
- D. Choose which clinic staff member to work with.
Correct Answer: C
Rationale: Residual schizophrenia can cause ambivalence or difficulty making decisions. Offering simple choices reduces decision-making stress and promotes autonomy.
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.