Nokea
The family of a client mentions to the nurse, 'The family therapist talked to us about enmeshment. We're not sure we understood what it meant.' The nurse should base a response on knowledge that an enmeshed family is a unit in which:
- A. individuality is encouraged.
- B. boundaries are poorly defined.
- C. conflict is effectively resolved.
- D. social acceptance is deemed unimportant.
Correct Answer: B
Rationale: The correct answer is B: boundaries are poorly defined. In an enmeshed family, boundaries between family members are blurred, leading to a lack of individual autonomy and independence. Enmeshment can result in difficulties in establishing personal identities and healthy relationships. Choices A, C, and D are incorrect because individuality is not encouraged, conflict is not effectively resolved, and social acceptance is not necessarily deemed unimportant in an enmeshed family dynamic.
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When undertaking care for a patient with an eating disorder, a nurse should first:
- A. perform a complete patient assessment.
- B. obtain a history from the patient's family.
- C. examine his or her own feelings about weight.
- D. question the patient as to when he or she last ate a meal.
Correct Answer: C
Rationale: The correct answer is C because examining the nurse's own feelings about weight is essential to ensure they have a neutral and non-judgmental attitude towards the patient. This self-awareness helps the nurse avoid projecting biases onto the patient and fosters a therapeutic relationship. Performing a complete patient assessment (A) is important but not the first step. Obtaining a history from the patient's family (B) may be helpful but is not the initial priority. Questioning the patient about their last meal (D) is important but does not address the nurse's own attitudes and biases that could impact care.
A 75-year-old patient comes to the clinic reporting frequent headaches. As the nurse begins the interaction, which action is most important?
- A. Complete a neurological assessment
- B. Determine whether the patient can hear as the nurse speaks
- C. Suggest that the patient lie down in a darkened room for a few minutes
- D. Administer medication to relieve the patient's pain before continuing the assessment
Correct Answer: B
Rationale: Before proceeding with any further assessment, the nurse should assess the patients ability to hear questions. Impaired hearing could lead to inaccurate answers.
A client with borderline personality disorder is having difficulty with memories of sexual abuse. She has a history of suicidal gestures, self-mutilation, sexual addiction, and substance addiction. She complains of vague pains, menstrual problems, and headaches. She entered the partial hospital program to prevent another suicide gesture or self-mutilation. The nurse recognizes that collaborative therapy may be helpful for this client and knows that the most useful collaboration in this case would be the client, the nurse, and the:
- A. Occupational therapist exploring ways to reduce stress
- B. Physical therapist exploring ways to reduce back pain
- C. Acupuncturist exploring ways to reduce pain
- D. Sexologist exploring healthy sexuality and safe sex
Correct Answer: A
Rationale: The correct answer is A: Occupational therapist exploring ways to reduce stress. In the case of a client with borderline personality disorder experiencing trauma-related symptoms, such as memories of sexual abuse, the focus is on addressing underlying emotional issues and coping strategies. Collaborative therapy involving the client, nurse, and occupational therapist can be beneficial. The occupational therapist can help the client develop coping skills, manage stress, and improve daily functioning. This approach targets the root of the client's difficulties and provides holistic support.
Summary:
- Choice B (Physical therapist exploring ways to reduce back pain): This option does not directly address the client's primary concerns related to trauma and emotional distress.
- Choice C (Acupuncturist exploring ways to reduce pain): While pain management is important, it does not address the client's complex psychological needs and trauma history.
- Choice D (Sexologist exploring healthy sexuality and safe sex): While important in some cases, focusing solely on sexuality does not address the broader range of issues the client
Which nursing progress note would most suggest that the treatment plan of a severely depressed and withdrawn patient has been effective?
- A. Slept 6 hours straight, sang with activity group, eager to see grandchild.
- B. Slept 8 hours, attended craft group, ate half of lunch, denies suicidal ideation.
- C. Slept 10 hours, personal hygiene adequate with assistance, lost one pound.
- D. Slept 7 hours on and off, reports "food has no taste", no self-harm noted.
Correct Answer: A
Rationale: The correct answer is A because it indicates positive changes in mood, engagement, and social interaction, which are key indicators of effective treatment for severe depression. Sleeping 6 hours straight shows improved sleep patterns, singing with the activity group reflects increased participation and enjoyment, and being eager to see the grandchild demonstrates a renewed sense of joy and connection.
Choice B is incorrect because although the patient denies suicidal ideation, the level of activity and engagement is not as high as in choice A. Choice C is incorrect as the focus is on physical aspects rather than emotional well-being and social interaction. Choice D is incorrect because the patient still shows signs of depression such as lack of appetite and loss of interest in activities.
To plan effective interventions, the nurse should understand that the underlying reason a patient with paranoid personality disorder is so critical of others probably lies in the patient's:
- A. need to control all aspects of the world around him.
- B. use of intellectualization to protect against anxiety.
- C. inflexible view of the environment and the people in it.
- D. projection of blame for his own shortcomings onto others.
Correct Answer: D
Rationale: The correct answer is D because paranoid personality disorder is characterized by distrust and suspicion of others, leading individuals to project their own negative traits onto others (projection). This defense mechanism helps them avoid accepting their own shortcomings. Option A is incorrect because the focus is on control, not blame. Option B is incorrect as intellectualization is a defense mechanism that involves avoiding emotions by focusing on rational aspects. Option C is incorrect as it refers to rigidity and not projection of blame. In summary, projection of blame onto others is the underlying reason for the critical behavior in paranoid personality disorder.