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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 correct answer is A: Risk for suicide related to recent deaths of significant others. This is the priority because the patient's recent losses put them at high risk for suicide. The nurse must assess the patient's risk level and provide appropriate interventions to prevent harm. Choices B, C, and D are incorrect because anxiety and social isolation are secondary concerns compared to the immediate risk of suicide. Spiritual distress, while important, does not take precedence over the patient's safety.
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A 72-year-old client with dementia, who resides in a long-term care facility, frequently goes to her room and cries because she misses her children. This client could benefit most from which intervention?
- A. Life review
- B. Doll therapy
- C. Comfort touch
- D. Audio presence therapy
Correct Answer: D
Rationale: The correct answer is D, Audio presence therapy. This intervention involves playing recordings of loved ones' voices to provide comfort and emotional support. For a client with dementia missing her children, hearing their voices can help reduce feelings of loneliness and provide a sense of connection. Life review (A) may not directly address the client's current emotional needs. Doll therapy (B) and comfort touch (C) may provide some comfort but may not be as effective as directly hearing the voices of her children through audio presence therapy (D).
Impaired environmental interpretation syndrome related to metabolic disorders is a condition that affects how the body processes nutrients and energy.
- A. Impaired environmental interpretation related to metabolic disorders.
- B. Impaired environmental interpretation related to cognitive disorders.
- C. Impaired environmental interpretation related to sensory disorders.
- D. None of the above.
Correct Answer: A
Rationale: The correct answer is A because the term "environmental interpretation" refers to how the body processes external stimuli, which can be affected by metabolic disorders. Choice B is incorrect as cognitive disorders do not directly impact environmental interpretation. Choice C is incorrect as sensory disorders specifically affect sensory processing, not environmental interpretation. Choice D is incorrect as option A accurately reflects the relationship between impaired environmental interpretation and metabolic disorders.
The nurse notes that a male client, who is taking an antipsychotic medication, is constantly moving from chair to chair during a group activity, and he complains that he feels 'nervous and jittery inside.' The nurse is aware that this client most likely is experiencing:
- A. Akinesia
- B. Dystonia
- C. Dyskinesia
- D. Akathisia
Correct Answer: D
Rationale: The correct answer is D: Akathisia. Akathisia is a common side effect of antipsychotic medications characterized by restlessness, inability to sit still, and a feeling of inner restlessness or jitteriness. In this case, the client's constant movement and feeling of nervousness align with the symptoms of akathisia.
A: Akinesia is the opposite of what the client is experiencing, characterized by a lack of movement or muscle weakness.
B: Dystonia involves involuntary muscle contractions and abnormal postures, not constant movement.
C: Dyskinesia refers to abnormal, involuntary movements of the face, trunk, and limbs, which are not described in the scenario.
It is a secondary dementia indicated by loss of recent memory and disorientation to time and place.
- A. Alzheimer's disease.
- B. Vascular dementia.
- C. Lewy body dementia.
- D. None of the above.
Correct Answer: A
Rationale: The correct answer is A: Alzheimer's disease. Alzheimer's disease is a common type of dementia characterized by progressive cognitive decline, including loss of recent memory and disorientation to time and place. This is due to the accumulation of amyloid plaques and neurofibrillary tangles in the brain. Vascular dementia (B) is caused by reduced blood flow to the brain, leading to cognitive impairment. Lewy body dementia (C) is characterized by the presence of abnormal protein deposits called Lewy bodies in the brain. Choosing D (None of the above) would be incorrect as Alzheimer's disease specifically matches the description provided in the question.
Which situation would be most likely to serve as a trigger to a catastrophic reaction in a client with stage 2 Alzheimer's disease?
- A. Participating in singing 'Happy Birthday' to another client at dinner
- B. Being scolded by an aide for spilling a glass of milk
- C. Listening to Big Band music from the 1940s
- D. Eating cupcakes in the activities room
Correct Answer: B
Rationale: The correct answer is B because being scolded for spilling milk can trigger feelings of shame, embarrassment, and confusion in a person with Alzheimer's stage 2. This negative interaction can lead to heightened agitation, aggression, or emotional distress due to the client's impaired ability to process and regulate emotions. In contrast, choices A, C, and D involve positive or neutral activities that are less likely to evoke such strong negative emotions or reactions in someone with Alzheimer's disease.