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In the elderly, administering medication is a great concern for the nurse since these patients are more prone to side effects. The primary cause of this is:
- A. Altered circulation and renal function
- B. Accelerated gastrointestinal system
- C. Enlarged Lymph nodes
- D. Musculoskeletal system weakness
Correct Answer: A
Rationale: Aging causes decreased renal and hepatic function, leading to slower metabolism and clearance of drugs, making older adults more vulnerable to drug toxicity and side effects. Other options, such as accelerated gastrointestinal function, are incorrect as GI motility often slows with age.
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An advance directive gives legally binding direction for health care interventions when a patient:
- A. Has a new diagnosis of cancer.
- B. Is diagnosed with Parkinson's disease
- C. Diagnosed with amyotrophic lateral sclerosis is unable to speak.
- D. Is unable to make decisions for self because of illness.
Correct Answer: D
Rationale: An advance directive is used when a patient is unable to make their own healthcare decisions, typically due to a serious illness or injury. This legal document outlines the patient’s wishes for treatment and care.
A patient asks the nurse manager to help resolve a situation between her and another patient. Which action would best support the patient’s feelings of safety when experimenting with new ways of being?
- A. Encouraging the patient to report the incident to the other patient’s physician
- B. Intervening on the patient’s behalf and sorting out the incident with the other patient
- C. Suggesting that the patient ignore the situation since the other patient was probably not aware of her behavior
- D. Offering to be present and help the patient discusses her feelings about the incident with the other patient
Correct Answer: D
Rationale: Offering to be present and help the patient discuss her feelings about the incident with the other patient would best support the patient’s feelings of safety when experimenting with new ways of being. This option encourages open communication between the two patients in a safe and mediated environment. It allows the patient to express her feelings assertively while feeling supported by the nurse manager. Mediation can help both patients understand each other's perspectives, resolve conflicts, and potentially prevent similar incidents in the future. Ultimately, this approach empowers the patient to address the situation directly while providing a sense of safety and support.
A 34-year-old male with catatonic schizophrenia has been mute and motionless for several days. Which nursing intervention would be an initial priority?
- A. Orienting the patient to the unit.
- B. Reinforcing reality with the patient.
- C. Establishing a nonthreatening relationship.
- D. Administer prescribed medications or intervention
Correct Answer: C
Rationale: Building trust and rapport is essential when working with patients in a catatonic or withdrawn state.
Which complaint is representative of anxiety in a 6-year-old child?
- A. I worry that my dad will get hurt at work.
- B. I get a stomach ache when it's my weekend at my dad's house.
- C. I can't sleep when I stay at Grandma's because I worry about my mom.
- D. I'm not going to sports camp because I don't like being away from my friends.
Correct Answer: B
Rationale: Children often express anxiety through physical complaints like stomachaches, especially in situations that cause distress or discomfort, such as visiting a noncustodial parent.
A 19-year-old patient with undifferentiated schizophrenia is acutely psychotic. The nurse assesses the primary deficit as:
- A. Social isolation
- B. Disturbed thinking
- C. Altered mood states
- D. Poor impulse control
Correct Answer: B
Rationale: Acute psychosis primarily affects thought processes, evidenced by delusions or disorganized thinking.