Nokea
The priority nursing focus for the period immediately after electroconvulsive therapy treatment should be on:
- A. Monitoring for the return of the capacity for full range of motion.
- B. Assessing the degree of accumulating memory impairment.
- C. Making positive comments while the patient is more receptive.
- D. Assessing the level of consciousness and normal body functions.
Correct Answer: D
Rationale: The correct answer is D: Assessing the level of consciousness and normal body functions. After electroconvulsive therapy (ECT), it is crucial to monitor the patient's level of consciousness and ensure all body functions are normal to detect any potential complications immediately. This includes assessing vital signs, neurological status, respiratory function, and cardiovascular stability. Monitoring for the return of full range of motion (A) is not a priority immediately post-ECT. Assessing memory impairment (B) may be important but is not the immediate priority. Making positive comments (C) is helpful for emotional support but does not address the critical need to assess physical status.
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Which information is most important to obtain during assessment of an older adult diagnosed with a mental disorder?
- A. Functional ability and emotional status
- B. Chronological age and sexual function
- C. Economic status and sources of income
- D. Developmental history, interests, and activities
Correct Answer: A
Rationale: Information related to functional ability and emotional status provides an overview of patient problems and abilities. It guides selection of interventions and services to meet identified needs. The distracters reflect information of relevance, but are not of highest priority.
A client with dementia is unable to name ordinary objects. Instead, he describes them (e.g., 'the thing you cut meat with'). The nurse should assess this as:
- A. Aphasia.
- B. Paraphasia.
- C. Apraxia.
- D. None of the above.
Correct Answer: B
Rationale: The correct answer is B: Paraphasia. Paraphasia is a language disturbance characterized by the substitution of one word for another, leading to incorrect or nonsensical speech. In the case of the client with dementia unable to name ordinary objects but describing them, such as 'the thing you cut meat with,' this behavior aligns with paraphasia. Aphasia (choice A) refers to a complete loss or impairment of language function, which is not the case here. Apraxia (choice C) involves the inability to perform purposeful movements, not language deficits. Therefore, the client's behavior is best assessed as paraphasia due to the characteristic word substitutions and descriptions given.
An elderly patient brings a bag of medications to the clinic. The nurse finds bottles of medications as well as assorted pills in no containers in the bag. What is the nurse's priority action?
- A. Dispose of all medications that are not in properly labeled bottles.
- B. Confer with a family member about the patient's management of medication.
- C. Engage the patient in education about safe storage and labeling of medication.
- D. Ask the patient to name the purpose and date of expiration of each medication not in a bottle.
Correct Answer: C
Rationale: The correct answer is C because engaging the patient in education about safe storage and labeling of medication is the priority action. This approach promotes patient understanding and empowerment in managing their medications safely. It addresses the immediate concern of the medications being improperly stored and unlabeled. Option A focuses solely on disposal without addressing the root cause. Option B involves a third party and may not address the patient's immediate needs. Option D is important but not as urgent as ensuring safe storage and labeling. Ultimately, educating the patient promotes long-term safety and adherence to medication management.
A 16-year-old female patient who is Chinese American is admitted to the unit with reports of sadness and suicidal ideation. The patient is accompanied by many family members, including her mother and father. The patient and her family emigrated from mainland China five years ago. Regarding the family, the psychiatric-mental health nurse:
- A. encourages the patient to communicate her need for privacy to her family
- B. gently asks the family members to leave the room
- C. privately asks the mother for her assistance in clearing the room
- D. provides care for the patient while the family members are present
Correct Answer: C
Rationale: Involving the mother respects cultural family dynamics while facilitating a private assessment, balancing sensitivity and need.
A nurse would assess for which feature in a patient diagnosed with anorexia nervosa without bingeing or purging?
- A. Extroverted personality traits
- B. Abuse of diuretics and laxatives
- C. Claims of sexual activity
- D. Denial of hunger at all times
Correct Answer: D
Rationale: The correct answer is D: Denial of hunger at all times. In anorexia nervosa without bingeing or purging, patients typically deny hunger despite severe weight loss. This is due to their distorted body image and fear of gaining weight. Assessing for denial of hunger helps in understanding their mindset and severity of the disorder.
Explanation of why other choices are incorrect:
A: Extroverted personality traits - Anorexia nervosa is often associated with introverted personality traits, not extroverted.
B: Abuse of diuretics and laxatives - This behavior is more characteristic of bulimia nervosa, not anorexia nervosa without bingeing or purging.
C: Claims of sexual activity - This choice is unrelated to the typical features of anorexia nervosa without bingeing or purging.