Nokea
The daughter of an 84-year-old client with dementia tearfully tells the nurse that she doesn't know what's wrong with her mother, who has begun accusing the family of stealing her lingerie and holding her prisoner. The nurse identifies which of the following nursing diagnosis for the client?
- A. Disturbed thought processes
- B. Powerlessness
- C. Ineffective coping
- D. Defensive coping
Correct Answer: A
Rationale: The correct answer is A: Disturbed thought processes. This nursing diagnosis is appropriate because the client's symptoms suggest cognitive impairment and delusions, which are common in dementia. The client's accusations of theft and imprisonment indicate a distortion in reality perception, reflecting disturbed thought processes. Powerlessness (B) relates more to lack of control over circumstances, not cognitive issues. Ineffective coping (C) and Defensive coping (D) focus on emotional responses rather than cognitive impairment.
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A patient with antisocial personality disorder tells Nurse A, 'You're a much better nurse than Nurse B said you were.' The patient tells Nurse B, 'Nurse A's upset with you for some reason.' To Nurse C the patient states, 'You'd like to think you're perfect, but I've seen three of your mistakes this morning.' These comments can best be assessed as:
- A. seductive.
- B. detached.
- C. guilt producing.
- D. manipulative.
Correct Answer: D
Rationale: The correct answer is D: manipulative. The patient is using different strategies to manipulate each nurse's emotions and behavior for personal gain. In the first scenario, the patient is attempting to create a divide between Nurse A and Nurse B by praising Nurse A and implying Nurse B's incompetence. In the second scenario, the patient is trying to instigate conflict between Nurse A and Nurse B by falsely suggesting Nurse A's negative feelings towards Nurse B. In the third scenario, the patient is employing a manipulative tactic by undermining Nurse C's confidence and competence. These behaviors demonstrate a pattern of manipulation aimed at controlling and influencing the nurses' perceptions and actions. Choices A, B, and C do not accurately capture the manipulative intent behind the patient's actions.
Which beliefs by a nurse facilitate provision of safe, effective care for older adult patients? Select one tha does not apply.
- A. Sexual interest declines with aging.
- B. Older adults are able to learn new tasks.
- C. Aging results in a decline in restorative sleep.
- D. Older adults are prone to become crime victims.
Correct Answer: A
Rationale: Older adults can learn new tasks (B), experience a decline in restorative sleep (C), and are prone to crime (D), aiding effective care. Sexual interest doesn't universally decline (A), and isolation isn't typical (E); these are myths.
What is the priority assessment for a patient with bulimia nervosa who is experiencing frequent purging behaviors?
- A. Monitor for signs of electrolyte imbalances and dehydration.
- B. Assess for any weight gain and increase exercise habits.
- C. Encourage the patient to express feelings about food and body image.
- D. Monitor for compulsive eating behaviors and binge episodes.
Correct Answer: A
Rationale: The correct answer is A: Monitor for signs of electrolyte imbalances and dehydration. This is the priority assessment for a patient with bulimia nervosa who is experiencing frequent purging behaviors because purging can lead to electrolyte imbalances and dehydration, which can result in serious health complications such as cardiac arrhythmias and renal issues. Monitoring electrolyte levels and hydration status is crucial for the patient's safety and well-being.
Summary:
- Choice B is incorrect because focusing on weight gain and exercise habits is not the priority when dealing with the immediate health risks of electrolyte imbalances and dehydration.
- Choice C is incorrect as expressing feelings about food and body image is important for therapy but not the priority in this acute situation.
- Choice D is incorrect as monitoring for compulsive eating behaviors and binge episodes is more relevant for patients with binge eating disorder rather than bulimia nervosa with frequent purging behaviors.
schizophrenia usually involves delusions of persecution and grandeur
- A. Catatonic
- B. Disorganized
- C. Paranoid
- D. Undifferentiated
Correct Answer: C
Rationale: Paranoid schizophrenia is marked by prominent delusions of persecution or grandeur.
A woman whose husband physically abuses her mentions to the nurse, 'Someday I'll have to leave him.' Which of the following would be the nurse's best response?
- A. Yes, you should, before he harms you badly.'
- B. Could we talk about developing a safety plan?'
- C. Are you afraid of what your family will say?'
- D. I don't know why you would stay with him.'
Correct Answer: B
Rationale: The correct answer is B: "Could we talk about developing a safety plan?" This response is the best choice as it acknowledges the woman's situation, offers support, and focuses on practical steps to ensure her safety. By suggesting a safety plan, the nurse is addressing the immediate concern of potential harm and empowering the woman to take control of her situation.
Incorrect Choices:
A: This response is too direct and may not take into account the complexities of the woman's situation. It lacks empathy and does not offer a constructive solution.
C: This response shifts the focus away from the woman's safety and onto external factors. It may come across as judgmental and unhelpful.
D: This response is dismissive and fails to acknowledge the seriousness of the situation. It does not offer any support or guidance to the woman in need.