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The home care nurse assessed a client with a history of dementia who had a herniorrhaphy at an ambulatory surgical center the previous day. The client lives in a senior retirement community and has no close family. The nurse assesses mild dysphasia. The client cannot remember why he has a bandage. He thinks he is in the army and that it is 1950. Appropriate planning for the client should include:
- A. Arranging an appointment at a geriatric assessment program; OT referral for swallowing therapy; teaching to manage public transportation
- B. Attending English class to improve speech; transferring finances to a conservator; employing an aide to help with medications
- C. Arranging Meals on Wheels, attending speech therapy; relocation to a skilled nursing facility if no improvement in 1 month
- D. Assessing diet and meal preparation; assessing environment for safety problems; referral to a dementia program
Correct Answer: D
Rationale: The correct answer, D, is the most appropriate plan because it addresses the client's current needs and safety concerns. Firstly, assessing diet and meal preparation is important due to the client's dysphasia, which may impact their ability to eat safely. Secondly, assessing the environment for safety problems is crucial as the client has dementia and may be at risk of accidents. Lastly, referral to a dementia program is necessary to provide specialized care and support for the client's condition.
Choices A, B, and C are incorrect because they do not directly address the specific needs of the client in terms of dementia, dysphasia, and safety concerns. They focus on unrelated interventions that are not as critical in this scenario.
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Which theory of etiology of Alzheimer's disease, suggested by current research, might the nurse use to help a family understand that this disorder is not of psychosocial origin? Alzheimer's disease is associated with:
- A. @-amyloid protein deposits in the brain
- B. Abnormal serotonin reuptake
- C. Excessive acetylcholine in the frontal cortex
- D. Prion infection of gray matter
Correct Answer: A
Rationale: The correct answer is A: @-amyloid protein deposits in the brain. This theory of Alzheimer's etiology is supported by current research, indicating that the accumulation of @-amyloid protein plaques in the brain is a key characteristic of the disease. These plaques lead to neuronal damage and cognitive decline. Option B, abnormal serotonin reuptake, is not associated with Alzheimer's. Option C, excessive acetylcholine in the frontal cortex, is incorrect as Alzheimer's is characterized by acetylcholine deficiency. Option D, prion infection of gray matter, is not linked to Alzheimer's disease. In summary, the presence of @-amyloid protein deposits in the brain is a key feature of Alzheimer's pathology, distinguishing it from psychosocial origins.
A student transfers from a hometown college to a university 200 miles away after breaking up with her boyfriend of 2 years. She was slow to make friends at the university. The history shows a close relationship with her mother and sister. She began eating large quantities when she felt sad, and then she induced vomiting. When the student's schoolwork declined, she sought help from the university health clinic. During the initial interview, what priority issue should the nurse address?
- A. Losses
- B. Sleep patterns
- C. School activities
- D. Menstrual flow
Correct Answer: A
Rationale: The correct answer, Losses (choice A), should be the priority issue for the nurse to address during the initial interview with the student. The rationale is as follows:
1. **Emotional Impact of Breakup**: The student's recent breakup is a significant loss that can trigger emotional distress.
2. **Social Isolation**: Slow to make friends at the university could indicate feelings of loneliness and isolation, further exacerbating the impact of the breakup.
3. **Eating Disorder Behaviors**: Eating large quantities and inducing vomiting are maladaptive coping mechanisms linked to emotional distress and loss.
4. **Academic Decline**: The decline in schoolwork could be a manifestation of the student's emotional struggles related to loss.
5. **Relationship with Family**: Close relationship with her mother and sister may also influence how she copes with losses and seeks support.
Summary:
- **Sleep Patterns (choice B)**: While important, sleep patterns are secondary to addressing the student's emotional distress and coping mechanisms related
Which nursing strategy leads patients to respond more positively to limit setting?
- A. Confront the patient with the inappropriateness of the behavior.
- B. Explore with the patient the underlying dynamics of the behavior.
- C. Reflect back to the patient an understanding of the patient's distress.
- D. State clear disapproval of the behavior, and support its consequences.
Correct Answer: C
Rationale: The correct answer is C because reflecting back to the patient an understanding of their distress shows empathy and validation, which can help build a therapeutic relationship and lead to a more positive response to limit setting. This approach acknowledges the patient's feelings without judgment, fostering trust and cooperation.
Choice A is incorrect as confrontation may lead to defensiveness and resistance. Choice B is incorrect as exploring underlying dynamics may not address the immediate need for setting limits. Choice D is incorrect as clear disapproval and consequences may create a negative, punitive atmosphere rather than promoting understanding and collaboration.
A 35-year-old woman who is being interviewed by the advanced practice nurse indicates that she has few friends, fears criticism from others, and withholds information about her thoughts and feelings because she anticipates a negative reaction. Based on these data, the nurse suspects that Sarah may later be diagnosed as having:
- A. Borderline personality disorder
- B. Histrionic personality disorder
- C. Avoidant personality disorder
- D. Schizoid personality disorder
Correct Answer: C
Rationale: The correct answer is C: Avoidant personality disorder. This is because the woman's fear of criticism, avoidance of sharing thoughts/feelings, and limited social circle are indicative of social inhibition and feelings of inadequacy, which are key features of avoidant personality disorder.
A: Borderline personality disorder is characterized by unstable relationships, self-image, and emotions, as well as impulsivity and fear of abandonment.
B: Histrionic personality disorder involves attention-seeking behavior, emotions that are shallow and rapidly shifting, and the need to be the center of attention.
D: Schizoid personality disorder is marked by social detachment, limited emotional expression, and preference for solitary activities.
The intervention that would be most appropriate of a male client develops orthostatic hypotension while taking amitriptyline (Elavil) is
- A. Consulting with the physician about substituting a different type of antidepressant
- B. Advising the client to sit up for 1 minute before getting out of bed
- C. Instructing the client to double the dosage until the problem resolves.
- D. Instruct the client to stop medication immediately
Correct Answer: B
Rationale: Advising the client to sit up slowly helps manage orthostatic hypotension, a common side effect of amitriptyline, by preventing sudden drops in blood pressure.