Nokea
The patient tells his primary nurse 'I get into trouble because I have hair-trigger responses. I shoot from the hip. Lots of times that gets me into a mess.' Which response would be most therapeutic?
- A. Let's look at ways to help you slow it down and think before acting.'
- B. It might help to explore how you came to be that way"“any ideas?'
- C. I'll bet you have some interesting stories to share about overreacting.'
- D. It's good that you're showing readiness and motivation to change.'
Correct Answer: A
Rationale: The correct answer is A because it demonstrates empathy and offers a therapeutic approach to help the patient manage their hair-trigger responses. By suggesting ways to slow down and think before acting, the nurse is providing practical strategies for the patient to work on self-regulation and impulse control. This response shows active listening and a commitment to supporting the patient in developing coping mechanisms.
Option B is incorrect as it focuses on exploring the root cause rather than offering immediate support. Option C is incorrect as it may encourage dwelling on past mistakes rather than focusing on problem-solving. Option D is incorrect as it praises the patient without addressing the need for behavior change.
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Which situation would be most likely to serve as a trigger to a catastrophic reaction in a client with stage 2 Alzheimer's disease?
- A. Participating in singing 'Happy Birthday' to another client at dinner
- B. Being scolded by an aide for spilling a glass of milk
- C. Listening to Big Band music from the 1940s
- D. Eating cupcakes in the activities room
Correct Answer: B
Rationale: The correct answer is B because being scolded for spilling milk can trigger feelings of shame, embarrassment, and confusion in a person with Alzheimer's stage 2. This negative interaction can lead to heightened agitation, aggression, or emotional distress due to the client's impaired ability to process and regulate emotions. In contrast, choices A, C, and D involve positive or neutral activities that are less likely to evoke such strong negative emotions or reactions in someone with Alzheimer's disease.
A person diagnosed with a serious mental illness enters a shelter for the homeless. Which intervention should be the nurses initial priority?
- A. Find supported employment
- B. Develop a trusting relationship
- C. Administer prescribed medication
- D. Teach appropriate health care practices
Correct Answer: B
Rationale: Basic psychosocial needs do not change because a person is homeless. The first step in caring for health care needs is establishing rapport. Once a trusting relationship is established, the nurse pursues other interventions.
When screening families for post-traumatic stress disorder following a major natural disaster, psychiatric-mental health nurses are practicing which type of disease prevention?
- A. Primary
- B. Secondary
- C. Tertiary
- D. Universal
Correct Answer: B
Rationale: Secondary prevention involves early detection (screening) to mitigate PTSD after exposure, unlike primary (prevention) or tertiary (rehabilitation).
In a sad voice, an elderly patient tells the nurse of the recent deaths of a spouse and close friend. The patient has no other family and only a few acquaintances in the community. The nurse's priority is to determine whether which nursing diagnosis applies to this patient?
- A. Risk for suicide related to recent deaths of significant others
- B. Anxiety related to sudden and abrupt lifestyle changes
- C. Social isolation related to loss of existing family
- D. Spiritual distress related to anger with God
Correct Answer: A
Rationale: The correct answer is A: Risk for suicide related to recent deaths of significant others. This is the priority because the patient's recent losses put them at high risk for suicide. The nurse must assess the patient's risk level and provide appropriate interventions to prevent harm. Choices B, C, and D are incorrect because anxiety and social isolation are secondary concerns compared to the immediate risk of suicide. Spiritual distress, while important, does not take precedence over the patient's safety.
A patient has a maladaptive response to eating regulation. Findings include the following: height, 5 feet 3 inches; current weight, 80 pounds with weight loss of 30% of body weight over the past 3 months; T, 96.6m F; BP, 68/40; P, 40; R, 20; poor skin turgor; lanugo; amenorrhea of 6 months' duration; admits to restricting intake to 350 calories daily; is a vegetarian; dissatisfied with eating pattern as evidenced by patient statement, 'I need to lose another 10 pounds to be at ideal weight'; diagnostic testing reveals serum potassium of 2.9 mEq/L and urine specific gravity of 1.028. Which of the following would be the highest priority nursing diagnosis for this patient?
- A. Imbalanced nutrition, less than body requirements.
- B. Disturbed body image.
- C. Deficient fluid volume.
- D. Powerlessness.
Correct Answer: C
Rationale: The correct answer is C: Deficient fluid volume. The patient is displaying signs of severe malnutrition and dehydration, as evidenced by significant weight loss, low blood pressure, low heart rate, and poor skin turgor. The low serum potassium and high urine specific gravity indicate dehydration. Addressing fluid volume deficiency is the top priority to stabilize the patient's condition and prevent further complications like electrolyte imbalances and organ damage. Choices A and B are important but secondary to addressing the immediate threat of dehydration. Choice D is not the priority as the patient's primary concern is physiological rather than psychological.