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Select the best outcome for a patient with the nursing diagnosis: "Impaired social interaction related to sociocultural dissonance as evidenced by stating, 'Although I’d like to, I don’t join in because I don’t speak the language very well.'” Patient will:
- A. Show improved use of language.
- B. Demonstrate improved social skills.
- C. Become more independent in decision-making.
- D. Select and participate in one group activity per day.
Correct Answer: D
Rationale: The correct answer is D: Select and participate in one group activity per day. This outcome directly addresses the nursing diagnosis of impaired social interaction by encouraging the patient to engage in a specific social activity daily. This goal promotes social interaction, helps the patient overcome language barriers, and gradually enhances their social skills. It provides a structured approach to improve the patient's sociocultural integration.
A: Show improved use of language - This choice focuses solely on language skills but does not directly address the social interaction issue.
B: Demonstrate improved social skills - While this choice is related to the nursing diagnosis, it is too broad and lacks specificity compared to choice D.
C: Become more independent in decision-making - This choice is not directly related to addressing impaired social interaction caused by language barriers.
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A patient asks, “What advantage does a durable power of attorney for health care have over a living will?” The nurse should reply, A durable power of attorney for health care:
- A. Gives your agent authority to make decisions during any illness if you are incapacitated.
- B. Can be given only to a relative, usually the next of kin, who has your best interests at heart.
- C. Can be used only if you have a terminal illness and become incapacitated.
- D. Cannot be implemented until 30 days after the documents are signed.
Correct Answer: A
Rationale: Correct Answer: A: Gives your agent authority to make decisions during any illness if you are incapacitated.
Rationale:
1. A durable power of attorney for health care allows you to appoint a trusted individual (agent) to make medical decisions on your behalf if you are unable to do so.
2. This authority is not limited to a specific type of illness or condition, ensuring your agent can make decisions for any illness that renders you incapacitated.
3. This flexibility ensures that your wishes are carried out regardless of the circumstances.
Summary of Other Choices:
B: Incorrect - A durable power of attorney can be given to any trusted individual, not just a relative.
C: Incorrect - A durable power of attorney can be used in any situation where you are unable to make decisions, not just in terminal illness.
D: Incorrect - A durable power of attorney can be implemented immediately upon signing, providing timely decision-making support.
The desired outcome for a patient experiencing insomnia is, "Patient will sleep for a minimum of 5 hours nightly within 7 days." At the end of 7 days, review of sleep data shows the patient sleeps an average of 4 hours nightly and takes a 2-hour afternoon nap. The nurse will document the outcome as:
- A. Consistently demonstrated.
- B. Often demonstrated.
- C. Sometimes demonstrated
- D. Never demonstrated.
Correct Answer: C
Rationale: The correct answer is C: Sometimes demonstrated. The rationale is that the patient is not consistently meeting the desired outcome of sleeping for a minimum of 5 hours nightly within 7 days. Although the patient is sleeping for an average of 4 hours nightly, the 2-hour afternoon nap indicates that the patient is not achieving the desired outcome consistently. Therefore, the nurse would document the outcome as "Sometimes demonstrated" to reflect that the patient is making progress towards the goal but has not fully achieved it. Choices A, B, and D are incorrect because the patient's sleep behavior does not align with being consistently, often, or never demonstrated based on the desired outcome criteria.
A patient living in community housing for the elderly says, “I don’t go to the senior citizens club. They play cards and talk about the past because that’s all they can do.” The nurse analyzes these remarks to represent:
- A. Failure to achieve developmental tasks
- B. Hypercritical behavior
- C. Paranoid thinking
- D. Thinking associated with ageism
Correct Answer: D
Rationale: The correct answer is D: Thinking associated with ageism. This is because the patient's statement reflects a negative stereotype about older adults, assuming they are limited to playing cards and reminiscing about the past. Ageism involves discrimination or prejudice based on someone's age, which can lead to stereotyping and marginalization.
A: Failure to achieve developmental tasks - This choice does not directly relate to the patient's statement about ageism.
B: Hypercritical behavior - The patient's statement does not indicate hypercritical behavior, but rather a biased perspective on aging.
C: Paranoid thinking - The patient's statement does not demonstrate paranoid thinking, but rather a biased view of older adults based on ageist beliefs.
In summary, the correct answer is D as the patient's remarks reflect ageist thinking, while the other choices do not align with the content of the patient's statement.
Which statement made by a patient just prior to being transported for a scheduled ECT treatment would result in cancellation of the treatment?
- A. “Will I remember having this treatment?”
- B. “Did eating some crackers cause any problems?”
- C. "Is this going to help me feel better soon?"
- D. "I feel like I need to ask more questions about the procedure."
Correct Answer: A
Rationale: The correct answer is A because asking about memory loss indicates a lack of informed consent and understanding of ECT procedure. Memory loss is a common side effect of ECT, and a patient should be well-informed about it before treatment. Choices B, C, and D do not raise concerns about the patient's understanding or readiness for ECT, making them incorrect. Choice B asks about dietary concerns, which do not directly impact the treatment. Choice C shows the patient's hope for improvement, which is a positive attitude. Choice D indicates the patient's desire for more information, which is a sign of engagement in their care.
The nurse counseling a patient with acute grief would assess the patient for:
- A. Severe depressive symptoms
- B. Conflicted and unresolved issues
- C. Increased arousal and hypervigilance
- D. Preoccupation with the image of the deceased
Correct Answer: B
Rationale: The correct answer is B because acute grief typically involves conflicting and unresolved emotions and thoughts related to the loss. The nurse would assess for unresolved issues to provide appropriate support and interventions. Choice A is incorrect as severe depressive symptoms may indicate complicated grief, not typical acute grief. Choice C is incorrect as increased arousal and hypervigilance are more characteristic of post-traumatic stress disorder. Choice D is incorrect as preoccupation with the image of the deceased may be a common experience in grief but does not encompass the full range of emotions and conflicts that acute grief entails.