Nokea
The nurse determines that the most effective point of intervention for bereavement is:
- A. Promotion of mental and spiritual health across the life spa
- B. At the time a newly discovered loss is impending
- C. Immediately after the loss has occurred
- D. When requested by the patient
Correct Answer: C
Rationale: The correct answer is C because intervening immediately after the loss has occurred allows for timely support and processing of emotions. This is crucial for healthy grieving and preventing complications. Choice A is too broad and not specific to the immediate need post-loss. Choice B focuses on pre-loss, which is not the most effective time for intervention. Choice D puts the responsibility on the patient, which may delay necessary support.
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A health care provider writes these new prescriptions for a resident in a skilled nursing facility: 2 G sodium diet, Restraint as needed, Limit fluids to 1800 mL daily, Continue antihypertensive medication, Milk of magnesia 30 mL PO once if no bowel movement for 3 days. The nurse should:
- A. Question the fluid restriction.
- B. Question the order for restraint.
- C. Transcribe the prescriptions as written.
- D. Assess the resident’s bowel elimination
Correct Answer: A
Rationale: Step 1: Fluid restriction of 1800 mL may not be appropriate for all residents in a skilled nursing facility. Step 2: Excessive fluid restriction can lead to dehydration, especially in elderly residents. Step 3: It is crucial for the nurse to question the fluid restriction to ensure it is safe for the resident. Therefore, the correct answer is A.
Summary:
- Option A is correct as questioning the fluid restriction is essential for the resident's safety.
- Option B is incorrect as restraining a resident should only be used as a last resort and should be questioned if not necessary.
- Option C is incorrect as blindly transcribing without assessing appropriateness can be harmful.
- Option D is incorrect as assessing bowel elimination is important but addressing the fluid restriction is more urgent in this scenario.
Immediately after electroconvulsive therapy (ECT), nursing care of the patient is most similar to care of a patient:
- A. With delirium tremens
- B. Recovering from conscious sedation
- C. With acute alcohol withdrawal
- D. Undergoing a routine diagnostic procedure
Correct Answer: B
Rationale: The correct answer is B: Recovering from conscious sedation. After ECT, patients are closely monitored as they recover from anesthesia and sedation. Nursing care involves assessing vital signs, mental status, and ensuring the patient's safety. This is similar to caring for a patient recovering from conscious sedation, where monitoring and observation are essential.
A: Delirium tremens involves severe alcohol withdrawal symptoms, which require specialized care including managing agitation and hallucinations.
C: Acute alcohol withdrawal requires specific interventions such as monitoring for seizures and providing medications to prevent complications.
D: Routine diagnostic procedures do not typically involve sedation or anesthesia, so the level of monitoring and care needed is different from post-ECT care.
A nurse and patient are entering the termination phase in the group experience. An important nursing intervention will be to:
- A. Encourage the group to describe goals for change.
- B. Inquire whether the group needs more time to accomplish goals.
- C. Assist the group to explore alternative coping strategies for problems
- D. Discuss feelings about leaving the group and the support found with the group.
Correct Answer: D
Rationale: The correct answer is D because discussing feelings about leaving the group and the support found within the group is crucial during the termination phase. This allows for processing emotions, reflecting on progress, and providing closure. Choice A focuses on future goals, not on the current phase. Choice B addresses time constraints, not emotional support. Choice C is about coping strategies, which may not be the priority during termination. Thus, D is the most appropriate intervention for this phase.
A community health nurse visits an elderly person whose spouse died 6 months ago. Two vodka bottles are in the trash. When the nurse asks about alcohol use, this person says, “I get lonely and drink a little to help me forget.” Select the nurse’s most therapeutic intervention.
- A. Assess whether this patient is drinking and driving.
- B. Teach the person about risks for alcoholism and suggest other coping strategies
- C. Advise the person not to drink alone because the risks for injury increase.
- D. Arrange for the person to attend an Alcoholics Anonymous meeting for older adults.
Correct Answer: B
Rationale: The correct answer is B: Teach the person about risks for alcoholism and suggest other coping strategies. This intervention is the most therapeutic because it addresses the underlying issue of using alcohol as a coping mechanism for loneliness and grief. By educating the person about the risks of alcoholism, the nurse can help the individual understand the potential harm of their current coping strategy. Additionally, suggesting alternative coping strategies can provide healthier ways to deal with loneliness and grief, ultimately promoting better overall well-being.
Choice A is incorrect because while assessing drinking and driving is important, it does not directly address the underlying emotional reasons for the alcohol use.
Choice C is incorrect as it focuses on the risks of injury rather than addressing the emotional aspects of the person's drinking behavior.
Choice D is incorrect as it jumps to a specific intervention without first addressing the person's understanding of their alcohol use and providing alternative coping strategies.
Which intervention will the nurse planning care for a patient with acute grief implement?a. Providing information about the grief process
- A. Providing information about the grief process.
- B. Suggesting utilization of community resources in a few weeks
- C. Encouraging dependence on the nurse for support
- D. Assessing for signs of complicated grief or depression
Correct Answer: A
Rationale: The correct answer is A because providing information about the grief process helps the patient understand their feelings and reactions, promoting emotional healing. Choice B is incorrect because suggesting community resources may not address the patient's immediate needs. Choice C is incorrect as encouraging dependence on the nurse may hinder the patient's ability to cope independently. Choice D is incorrect because assessing for complicated grief or depression is important but not the initial intervention in planning care for acute grief.