Nokea
What is a priority goal of involuntary hospitalization of the severely mentally ill client?
- A. Re-orientation to reality
- B. Elimination of symptoms
- C. Protection from harm to self or others
- D. Return to independent functioning
Correct Answer: C
Rationale: The priority goal of involuntary hospitalization of severely mentally ill clients is to ensure protection from harm to self or others. Involuntary hospitalization is often necessary for individuals who are deemed dangerous to themselves or others or who are considered gravely disabled. Re-orientation to reality, elimination of symptoms, and return to independent functioning are important aspects of mental health care but are not the primary goals of involuntary hospitalization. The main focus during involuntary hospitalization is to address safety concerns and prevent harm.
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The nurse is caring for a newly admitted patient. Which intervention is the best example of a culturally appropriate nursing intervention?
- A. Insist that family members provide most of the patient's personal care.
- B. Maintain a personal space of at least 2 feet when assessing the patient.
- C. Ask permission before touching a patient during the physical assessment.
- D. Consider the patient's ethnicity as an important factor in planning care.
Correct Answer: C
Rationale: Culturally appropriate nursing care requires sensitivity to the beliefs and practices of diverse cultural groups. Asking permission before touching a patient during a physical assessment is a universally respectful practice, as many cultures consider it disrespectful to touch a person without consent. This approach demonstrates respect for the patient's autonomy and cultural preferences. Maintaining a personal space of at least 2 feet can be a good practice for infection control or personal comfort but may not be culturally significant for all patients. Insisting that family members provide most of the patient's personal care may not align with the patient's cultural norms or preferences. Considering a patient's ethnicity as the most important factor in care planning overlooks the individuality of the patient and may lead to stereotyping or assumptions that are not accurate or helpful in providing tailored care.
What psychodynamic process is suggested by a client calling the emergency department during a suicide attempt?
- A. A cry for help
- B. A need for attention
- C. Ambivalence about dying
- D. An inability to stick to a decision
Correct Answer: C
Rationale: The correct answer is 'Ambivalence about dying.' When a client calls the emergency department during a suicide attempt, it suggests conflicting feelings about living and dying. This act can indicate an unconscious desire to be stopped from dying, showing ambivalence between the wish to die and the wish to live. It is not primarily a cry for attention or a need to punish others. The client's intention of suicide alongside seeking help demonstrates the struggle between life and death, making ambivalence the key psychodynamic process at play.
An older Asian American patient tells the nurse that she has lived in the United States for 50 years. The patient speaks English and lives in a predominantly Asian neighborhood. Which action by the nurse is most appropriate?
- A. Include a shaman when planning the patient's care
- B. Avoid direct eye contact with the patient during care
- C. Ask the patient about any special cultural beliefs or practices
- D. Involve the patient's oldest son to assist with health care decisions
Correct Answer: C
Rationale: The most appropriate action for the nurse in this scenario is to ask the patient about any special cultural beliefs or practices. This allows for a better understanding of the patient's individual cultural background and preferences related to healthcare. It is important to gather this information to provide culturally sensitive care. Choices A, B, and D are not appropriate actions. Including a shaman without the patient's request or consent may not align with the patient's beliefs or practices. Avoiding direct eye contact can be perceived as disrespectful in some cultures but should not be assumed without confirmation from the patient. Involving the patient's oldest son without the patient's consent or preference may not be appropriate and assumes family dynamics that may not be accurate.
After attending group therapy, the client says, 'It helps to know that I'm not the only one with this type of problem.' Which concept does this statement reflect?
- A. Altruism
- B. Catharsis
- C. Universality
- D. Transference
Correct Answer: C
Rationale: The client's statement reflects the concept of universality. Universality in group therapy signifies the understanding that one is not alone in their struggles, providing a sense of commonality and support among group members facing similar challenges. Altruism in group therapy involves offering support, insight, and encouragement to others, fostering personal growth and self-awareness. Catharsis pertains to group members sharing and expressing both negative and positive emotions with each other. Transference occurs when a client inadvertently projects feelings and perceptions onto the therapist that originally belonged to someone significant in their past, impacting the therapeutic relationship.
Which action by a client who requires an above-the-knee amputation for peripheral arterial disease best indicates emotional readiness for the surgery?
- A. Explains the goals of the procedure
- B. Displays few signs of anticipatory grief
- C. Participates in learning perioperative care
- D. Verbalizes acceptance of permanent dependency needs
Correct Answer: C
Rationale: Participating actively in learning self-care demonstrates emotional acceptance of the need for surgery and readiness for planning post-surgery. Explaining the goals of the procedure may reflect intellectual readiness but not necessarily emotional readiness. A client who shows few signs of anticipatory grief may be suppressing emotions or in denial, which can hinder the emotional readiness. Verbalizing acceptance of permanent dependency needs suggests the client may require further education and emotional support, as it may not reflect a healthy emotional readiness for the surgery.