Nokea
Joey is a 5-year-old who is causing his parents a lot of concern. His mother reports that he bounces off the walls all the time and cant focus on any one thing for very long. He is impulsive and has recently ran right out into the street in front of the familys home. His teacher has told his parents that he has done similar things at school. The nurse understands that:
- A. Joey shows all the signs of having ADHD and should probably be placed on Ritalin as soon as possible
- B. Joey is just an active, healthy child who needs to be disciplined more effectively
- C. Joey could be autistic, and additional testing will have to be done to confirm the diagnosis
- D. Joey shows signs of having ADHD, but is too young for that diagnosis to be made definitively now
Correct Answer: D
Rationale: Definitive diagnosis of ADHD should not be made before age 7 because developmentally the child has a shorter attention span.
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The outcome that should be established for an elderly patient with delirium caused by fever and dehydration is that the patient will:
- A. Return to a premorbid level of functioning.
- B. Demonstrate motor responses to noxious stimuli.
- C. Identify stressors negatively affecting self.
- D. None of the above.
Correct Answer: A
Rationale: The correct answer is A because the goal in managing delirium in an elderly patient is to restore them to their premorbid level of functioning. This involves addressing the underlying causes like fever and dehydration. Option B is incorrect as it focuses on a neurological response rather than the overall outcome for the patient. Option C is also incorrect as it pertains to identifying stressors, which is not the primary goal in managing delirium. Option D is incorrect as it dismisses the importance of restoring the patient to their baseline level of functioning.
Which statement by the nurse indicates a good understanding of postpartum blues?
- A. You need to get involved with taking care of this baby.
- B. You are lucky to have a healthy baby. The patient in the next room would give anything to be in your place.
- C. You look tired. Why dont you rest for a bit and I will come back later to start some teaching.
- D. I will call the social worker to check into alternate caregiving for the new baby.
Correct Answer: C
Rationale: This response (C) indicates understanding that postpartum blues is transient and that time and rest are major healers. The other responses (A, B, D) are judgmental or inappropriate.
A severely withdrawn patient diagnosed with schizophrenia will spend time in the dayroom but will not speak to staff or to other patients. The most therapeutic nursing intervention in response to this behavior would be to:
- A. seat the patient with a group of patients who are talking to each other.
- B. ignore the silence and talk about superficial topics such as the weather.
- C. point out that the patient makes others uncomfortable by refusing to speak.
- D. plan time for staff members to sit with the patient even though the patient does not talk with them.
Correct Answer: D
Rationale: The correct answer is D because it focuses on building a therapeutic relationship with the patient without placing pressure on them to speak. By planning time for staff members to sit with the patient, even if the patient does not talk, it allows for nonverbal communication and presence to convey support and care. This approach respects the patient's boundaries and allows them to engage at their own pace, fostering trust and a sense of safety.
Choice A is incorrect as it may overwhelm the patient by placing them in a social situation they are not ready for. Choice B is incorrect as discussing superficial topics does not address the patient's underlying issues. Choice C is incorrect as it may make the patient feel judged or pressured to speak, further isolating them.
A client with obsessive-compulsive personality disorder seeks treatment for depression after the recent breakup of a relationship. The client constantly procrastinated about proposing marriage and said his girlfriend complained that he did not show her affection and that he was too controlling. Now he describes inability to sleep, poor concentration, and loss of energy since the breakup. Which outcome is a priority for the client? The client will:
- A. Demonstrate assertive behavior
- B. Express hope for developing a new relationship in the future
- C. Identify feelings of sadness related to the failed relationship
- D. List three new ways to reduce stress
Correct Answer: C
Rationale: The correct answer is C: Identify feelings of sadness related to the failed relationship. This is the priority outcome because the client's current symptoms of depression, such as inability to sleep, poor concentration, and loss of energy, are likely related to the breakup. By identifying and processing feelings of sadness, the client can begin to work through the grief and emotional distress caused by the failed relationship, which can help alleviate the depressive symptoms.
Choice A (Demonstrate assertive behavior) is not the priority outcome as the client's primary issue is related to depression and processing emotions, not assertiveness. Choice B (Express hope for developing a new relationship in the future) may be important for the client's overall well-being, but it is not the immediate priority for addressing the current depressive symptoms. Choice D (List three new ways to reduce stress) may be helpful in managing symptoms, but it does not address the core issue of processing emotions related to the breakup.
A salesman has had difficulty holding a job because he accuses co-workers of conspiring to take his sales. Today, he argued with several office mates and threatened to kill one of them. The police were called, and he was brought to the mental health center for evaluation. He has had previous admissions to the unit for stabilization of paranoid schizophrenia. When the nurse meets him, he points at staff in the nursing station and states loudly, 'They're all plotting to destroy me. Isn't that true?' Which would be the most appropriate response?
- A. No, that is not true. People here are trying to help you if you will let them.'
- B. Let's think about it: what reason would people have to want to destroy you?'
- C. Thinking that people want to destroy you must be very frightening.'
- D. That doesn't make sense; staff are health care workers, not murderers.'
Correct Answer: C
Rationale: The correct answer is C: Thinking that people want to destroy you must be very frightening.
Rationale:
1. Acknowledges the patient's feelings: By stating that thinking people want to destroy him is frightening, the nurse shows empathy and validates his experience.
2. Validates the patient's emotions: This response does not directly agree or disagree but acknowledges the emotions behind the patient's statement.
3. Builds rapport: By showing understanding and empathy, the nurse can establish trust and rapport with the patient, leading to better communication and therapeutic relationship.
Summary of other options:
A: This response denies the patient's feelings and could potentially escalate the situation by invalidating his experiences.
B: This response may come off as confrontational and does not address the patient's underlying fears.
D: This response is dismissive and does not address the patient's emotional distress, potentially leading to further agitation.