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In response to the nurse’s statement, “Tell me about your family,” the patient became silent and displayed nonverbally that he is uncomfortable. Which statement by the nurse reflects sensitivity to the patient?
- A. “I’m so sorry. I didn’t realize your family was a problem for you.”
- B. “Learning to express negative feelings will assist you in getting well.”
- C. “Perhaps you can talk about your feelings to the physician next time you meet.”
- D. “That seems to be a difficult subject for you. We can discuss when you are
Correct Answer: D
Rationale: The correct answer is D because it acknowledges the patient's discomfort without making assumptions or judgments. By recognizing the difficulty the patient is facing and offering to discuss it when they are ready, the nurse shows empathy and respect for the patient's feelings.
Choice A is incorrect because it assumes the family is a problem for the patient. Choice B is incorrect because it focuses on expressing negative feelings rather than addressing the patient's current discomfort. Choice C is incorrect because it deflects the conversation to the physician without addressing the patient's immediate needs.
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A patient states, "I’m not worth anything. I have negative thoughts about myself. I feel anxious and shaky all the time. Sometimes I feel so sad that I want to go to sleep and never wake up." Which nursing intervention should have the highest priority?
- A. Self-esteem-building activities.
- B. Anxiety self-control measures.
- C. Sleep enhancement activities.
- D. Suicide precautions.
Correct Answer: D
Rationale: The correct answer is D: Suicide precautions. The patient's statement indicates they are experiencing severe depression and suicidal ideation. Suicide precautions should be the highest priority to ensure the patient's safety. This includes removing any potential means of self-harm, constant monitoring, and close supervision. Self-esteem-building activities (A) may be helpful in the long term but are not the immediate priority. Anxiety self-control measures (B) are important but addressing suicidal ideation takes precedence. Sleep enhancement activities (C) are also important but not the highest priority when dealing with suicidal thoughts.
Which description is characteristic of an impulsive child?
- A. Running out into the street regardless of frequent instruction to look both ways first.
- B. Pacing and speaking in a very loud, disruptive voice
- C. Frequently talking about hearing voices telling him what to do
- D. Having a difficult time concentrating on reading since his attention is easily diverted
Correct Answer: A
Rationale: The correct answer is A. An impulsive child typically acts without thinking or considering consequences, such as running into the street without looking. This behavior is impulsive, risky, and disregards safety instructions. Choices B and C describe behaviors that are more indicative of other issues like hyperactivity or hallucinations. Choice D suggests difficulty concentrating, which is not directly related to impulsivity. In summary, the key characteristic of an impulsive child is acting quickly without considering potential dangers or instructions.
When a patient asks the nurse, “How can jolting me with an electrical shock possibly do me any good?” the answer most reflective of current biologic theory would be:
- A. “ECT produces a change in brain chemistry that results in improved mood.
- B. “ECT provides you with external punishment so you can stop punishing yourself.”
- C. “ECT interrupts brain impulses that are causing hallucinations and delusions.”
- D. ECT shocks the brain into re-establishing normal electrical patterns.”
Correct Answer: A
Rationale: Step 1: Electroconvulsive therapy (ECT) is a treatment for severe depression and other mental health disorders.
Step 2: Current biological theory suggests that ECT produces changes in brain chemistry, specifically neurotransmitters, leading to improved mood.
Step 3: The correct answer (A) aligns with this theory by explaining how ECT impacts brain chemistry to alleviate symptoms.
Step 4: Answer B is incorrect as ECT is not used as punishment but as a therapeutic intervention.
Step 5: Answer C is incorrect as ECT is not primarily used to interrupt brain impulses causing hallucinations and delusions.
Step 6: Answer D is incorrect as ECT does not shock the brain into re-establishing normal electrical patterns but rather affects neurotransmitter levels.
The parents of an 8-year-old are attempting to help their child comprehend new information. Which intervention suggested by the nurse shows an understanding of the cognitive development theory for this age group?
- A. The use of drawing and illustrations
- B. Comparing the child’s experiences to the new material
- C. Encouraging the child to talk about this new information
- D. Asking the child to give a reason for how they feel about new information
Correct Answer: B
Rationale: The correct answer is B: Comparing the child’s experiences to the new material. At the age of 8, children are in the concrete operational stage according to Piaget's cognitive development theory. This stage is characterized by the ability to think logically about concrete events and understand the concept of conservation. By comparing the child's experiences to the new material, the parents are helping the child make connections between what they already know and the new information, which facilitates understanding. Drawing and illustrations (choice A) are helpful for visual learners but may not necessarily tap into the child's cognitive development stage. Encouraging the child to talk about new information (choice C) is beneficial for communication skills but may not directly address cognitive development. Asking the child to give a reason for how they feel about new information (choice D) focuses more on emotions rather than cognitive understanding.
A chronically depressed and suicidal client is admitted to a psychiatric unit. The client is scheduled for electroconvulsive therapy (ECT). During the course of ECT, a nurse should recognize the continued need for which critical intervention?
- A. Suicide assessment must continue throughout the ECT course.
- B. Antidepressant medications are contraindicated throughout the ECT course.
- C. Discourage expressions of hopelessness throughout the ECT course.
- D. Encourage a high-caloric diet throughout the ECT course.
Correct Answer: A
Rationale: The correct answer is A because suicide assessment must continue throughout the ECT course to ensure the safety and well-being of the client. During ECT, the client may experience changes in mood and behavior, which could impact their risk of suicide. It is essential for the nurse to monitor and assess the client's suicidal ideation and intent regularly. This ongoing assessment helps in identifying any exacerbation of suicidal thoughts and allows for timely intervention to prevent self-harm.
Choice B is incorrect because antidepressant medications are not necessarily contraindicated throughout the ECT course. In some cases, a client may still require antidepressants in addition to ECT for optimal treatment outcomes.
Choice C is incorrect because it is important to acknowledge and validate the client's feelings of hopelessness rather than discouraging them. By addressing and exploring these feelings, the nurse can provide support and facilitate the client's emotional processing.
Choice D is incorrect because encouraging a high-caloric diet is not directly related to the critical intervention needed during