Nokea
The highest priority for assessment by nurses caring for older adults who self-administer medications is:
- A. use of multiple drugs with anticholinergic effects.
- B. overuse of medications for erectile dysfunction.
- C. missed doses of medications for arthritis.
- D. trading medications with acquaintances.
Correct Answer: A
Rationale: Anticholinergic effects are cumulative in older adults and often have adverse consequences related to accidents and injuries (A), making it the highest priority. The other issues (B, C, D) may be relevant but are less critical.
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A normal person sees flashes of light while falling asleep. These are examples of
- A. Hypnopompic hallucinations
- B. Eidetic imagery
- C. Visual hallucinations
- D. Complex hallucinations
Correct Answer: C
Rationale: Flashes of light while falling asleep are hypnagogic visual hallucinations, a normal phenomenon, though 'visual hallucinations' is the closest match here.
Priority nursing interventions for a client with borderline personality disorder who has a history of self-mutilation and is currently angry, irritable, and impulsive would be:
- A. Establishing a contract for safety with the client
- B. Teaching the client ways to manage anger
- C. Helping the client tolerate feelings
- D. Implementing behavioral modification
Correct Answer: A
Rationale: The correct answer is A: Establishing a contract for safety with the client. This is the priority intervention as it focuses on ensuring the client's immediate safety. By setting up a contract for safety, the nurse can collaborate with the client on identifying warning signs and developing a plan to prevent self-harm.
Choice B (Teaching the client ways to manage anger) and Choice C (Helping the client tolerate feelings) are important interventions but may not be as urgent as ensuring the client's safety in this scenario.
Choice D (Implementing behavioral modification) is not the priority because the client's safety needs to be addressed first before focusing on behavioral changes.
A patient with bipolar disorder is hyperactive and has not slept for 3 days. Mood and behavior are labile. The patient threatens to hit another patient. Which response by the nurse is appropriate?
- A. Stop that now. No one did anything to provoke an attack by you.
- B. If you try that again, you will be placed in seclusion immediately.
- C. Do not hit anyone. If you are unable to control yourself, we will help you.
- D. You know we will not let you hit anyone. Why do you continue this behavior?
Correct Answer: C
Rationale: The correct answer is C because it acknowledges the patient's struggle to control their behavior and offers support. It emphasizes the importance of not hitting anyone while also reassuring the patient that help is available if needed. This response promotes a therapeutic environment by setting clear boundaries and offering assistance rather than using threats or aggression.
Choice A is incorrect as it may escalate the situation by using a confrontational tone, potentially provoking further aggression. Choice B is also incorrect as it threatens the patient with seclusion, which can be seen as punitive and may not address the underlying issues causing the behavior. Choice D is incorrect as it does not provide a clear directive to prevent violence and instead questions the patient's behavior without offering immediate support.
A student nurse visiting a senior center says, 'Its depressing to see these old people. They are weak and frail. I doubt any of them can engage in a discussion.' The student is expressing:
- A. reality
- B. ageism
- C. empathy
- D. vulnerability
Correct Answer: B
Rationale: Ageism is a bias against older people because of their age. None of the other options applies to the ideas expressed by the student.
Vascular dementia is more common in individuals living in:
- A. The United States
- B. Japan
- C. France
- D. Australia
Correct Answer: B
Rationale: The correct answer is B: Japan. Vascular dementia is more common in countries with a high prevalence of risk factors such as hypertension, diabetes, and cardiovascular diseases. Japan has a high prevalence of these risk factors due to lifestyle factors and aging population. The other choices (A, C, D) do not have the same level of risk factors or population demographics as Japan, making them less likely to have a higher incidence of vascular dementia.