Nokea
The outcome that should be established for an elderly patient with delirium caused by fever and dehydration is that the patient will:
- A. Return to a premorbid level of functioning.
- B. Demonstrate motor responses to noxious stimuli.
- C. Identify stressors negatively affecting self.
- D. None of the above.
Correct Answer: A
Rationale: The correct answer is A because the goal in managing delirium in an elderly patient is to restore them to their premorbid level of functioning. This involves addressing the underlying causes like fever and dehydration. Option B is incorrect as it focuses on a neurological response rather than the overall outcome for the patient. Option C is also incorrect as it pertains to identifying stressors, which is not the primary goal in managing delirium. Option D is incorrect as it dismisses the importance of restoring the patient to their baseline level of functioning.
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A group of teenagers are discussing their individual problems associated with having an eating disorder. Which findings would the nurse attribute to purging?
- A. Excessive facial hair
- B. Elevated blood pressure
- C. Polyuria
- D. Dental enamel erosion
Correct Answer: C
Rationale: Rationale for Correct Answer (C - Polyuria):
1. Purging involves self-induced vomiting or misuse of laxatives/diuretics.
2. Vomiting can lead to electrolyte imbalances, causing increased urine production (polyuria).
3. Polyuria is a common sign of purging behaviors due to electrolyte disturbances.
Summary of Incorrect Choices:
A: Excessive facial hair - Not directly related to purging behavior.
B: Elevated blood pressure - Could be related to stress or other factors, not specific to purging.
D: Dental enamel erosion - More likely associated with frequent vomiting (purging) rather than polyuria.
A patient reports, 'My brain is tapped by government agents who can trace my whereabouts and listen to my thoughts.' An appropriate nursing response to this information would be:
- A. Your story is very strange and too bizarre for me to believe.'
- B. Tell me why you think your brain is being tapped.'
- C. What was happening in your life just before you began to think your brain was tapped?'
- D. Are you feeling frightened or angry about the government violating your body?'
Correct Answer: C
Rationale: The correct response is C because it focuses on exploring the underlying reasons for the patient's belief, which can help uncover any triggers or stressors leading to the delusion. This approach shows empathy, builds rapport, and encourages the patient to share more about their experiences. Choice A is dismissive and may cause the patient to feel invalidated. Choice B only focuses on the belief itself without delving deeper into the context. Choice D jumps to assumptions about the patient's emotions without addressing the core issue of the delusion. Overall, choice C promotes therapeutic communication and understanding of the patient's perspective.
A nurse has recently been assigned to a unit that specializes in the care of patients diagnosed with eating disorders. The nurse should consider which of the following actions as having priority when preparing for this new assignment?
- A. Becoming familiar with the unit's policies and procedures.
- B. Arranging to mentor with a nurse who has experience on the unit.
- C. Self-reflecting on personal feelings regarding body weight and size.
- D. Attending an educational seminar that focuses on maladaptive eating disorders.
Correct Answer: C
Rationale: The correct answer is C. Self-reflecting on personal feelings regarding body weight and size is crucial for the nurse to be aware of any biases or triggers that may affect patient care. Understanding personal attitudes towards body image can prevent unintentional harm or judgment towards patients.
A: Becoming familiar with the unit's policies and procedures is important but not the top priority when dealing with patients with eating disorders.
B: Arranging to mentor with a nurse who has experience on the unit can be helpful but does not address the nurse's personal biases.
D: Attending an educational seminar is valuable but may not address the nurse's own attitudes towards body image.
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: Correct Answer: B. Determine whether the patient can hear as the nurse speaks.
Rationale:
1. Hearing assessment is crucial to ensure patient understanding and communication.
2. Hearing loss may affect compliance with treatment and safety.
3. Identifying hearing deficits early can prevent misunderstandings and improve patient outcomes.
Summary:
- A: While a neurological assessment may be necessary, addressing hearing first is more immediate.
- C: Suggesting rest may help with headache management, but addressing hearing is more critical.
- D: Administering medication is premature without assessing hearing first.
Which characteristic fits the usual profile of an individual diagnosed with pedophilic disorder?
- A. Homosexual
- B. Ritualistic behaviors
- C. Seeks access to children
- D. Self-confident professional
Correct Answer: C
Rationale: The correct answer is C because an individual diagnosed with pedophilic disorder typically seeks access to children for sexual purposes. This behavior is a key characteristic of pedophilia. Homosexuality (A) is not a defining factor in pedophilic disorder. Ritualistic behaviors (B) are not specific to pedophilia but may be present in some cases. Being a self-confident professional (D) does not correlate with pedophilic tendencies. In summary, seeking access to children (C) aligns with the diagnostic criteria for pedophilic disorder, making it the most fitting characteristic.