Nokea
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.
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A 70-year-old male has the nursing diagnosis of situational low self-esteem related to forced retirement. Using Maslow’s hierarchy, the nurse is confident the patient is meeting self-worth outcomes when the patient:
- A. Moves to a secure apartment building
- B. Exercises regularly with friends at the gym
- C. Attends his grandchildren’s school functions
- D. Volunteers at the local homeless shelter weekly
Correct Answer: D
Rationale: The correct answer is D because volunteering at the local homeless shelter fulfills the self-actualization need in Maslow's hierarchy. By helping others and contributing to the community, the patient gains a sense of purpose and fulfillment, boosting self-esteem.
A: Moving to a secure apartment building addresses safety needs, not self-esteem.
B: Exercising with friends promotes social belonging but does not directly address self-esteem.
C: Attending grandchildren's functions fosters social connections, but it may not directly impact self-esteem like volunteering does.
A grief support group is held at the local community center to assist persons who are dealing with issues of loss. Which remark by one of the members would the nurse interpret as indicating unresolved feelings of guilt?
- A. “I know that my husband had a good life.”
- B. “It seems I miss my son more as time goes on.”
- C. “I am still wishing I had gotten help to him sooner.”
- D. "The holidays are always so hard for me now."
Correct Answer: C
Rationale: The correct answer is C because the statement indicates feelings of guilt about not getting help sooner, suggesting the member may blame themselves for the loss. This remark reflects a sense of responsibility and regret, common in unresolved guilt. Choice A expresses acceptance, B reflects natural grief progression, and D highlights difficulty during specific times, not necessarily linked to guilt. By analyzing the content of each statement, the nurse can identify cues related to unresolved feelings of guilt.
During a bereavement group, one of the members states, “I should have been the one to die. My husband had so much to offer.” The member was expressing:
- A. Ambivalence and low self-esteem
- B. Unresolved anger toward her husband
- C. A need for attention from group members
- D. Depression
Correct Answer: A
Rationale: The correct answer is A: Ambivalence and low self-esteem. The member's statement reflects conflicting emotions (ambivalence) about her worth compared to her husband's. This indicates low self-esteem, as she believes she is less valuable. Unresolved anger (B) would involve blaming her husband, not herself. A need for attention (C) is not evident, as she is sharing personal feelings. Depression (D) may be present, but the statement specifically points to self-deprecation, not just a general feeling of sadness.
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.