Nokea
What is the priority nursing diagnosis for a catatonic patient?
- A. Ineffective coping
- B. Impaired physical mobility
- C. Risk for deficient fluid volume
- D. Impaired social interaction
Correct Answer: C
Rationale: The priority nursing diagnosis for a catatonic patient is Risk for deficient fluid volume (C) because catatonic patients are at risk for dehydration due to decreased fluid intake or inability to meet fluid needs. This diagnosis takes precedence over others as dehydration can lead to serious complications. Ineffective coping (A) may be secondary to the catatonic state but addressing fluid volume is more urgent. Impaired physical mobility (B) and Impaired social interaction (D) are important but not as critical as addressing the risk of dehydration in a catatonic patient.
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Which patient would the nurse determine to be at highest risk for dysfunctional grief? The patient:
- A. Whose 16-year-old daughter was raped and killed while going on an errand for the patient
- B. Whose 86-year-old mother, with whom she has shared her home, died after a long illness.
- C. Who attended a support group and had been assisted by hospice to care for her terminally
- D. Who attended a bereavement group, where she learned to express feelings after the deaths of her twin daughters
Correct Answer: A
Rationale: The correct answer is A because the patient whose 16-year-old daughter was raped and killed while going on an errand for the patient is at highest risk for dysfunctional grief. This traumatic and unexpected loss of a child to a violent act can lead to complicated or prolonged grief reactions. The sudden and violent nature of the death, along with the added trauma of rape, can significantly impact the grieving process. The intense emotions and feelings of guilt, anger, and helplessness may complicate the bereavement process and lead to dysfunctional grief reactions.
Summary:
Choice B is incorrect because the death of an 86-year-old mother after a long illness, although sad, does not necessarily indicate a higher risk of dysfunctional grief. Choice C is incorrect as attending a support group and receiving assistance from hospice are positive factors that can support healthy grieving. Choice D is incorrect as attending a bereavement group and learning to express feelings after the deaths of twin daughters indicate active engagement in the grieving process, which is
Which response by the nurse would best assist a patient in de-escalating aggressive behavior?
- A. "Tell me what’s going on."
- B. "Why are you getting so upset?"
- C. "If you throw something, you will be restrained."
- D. "It’s time for group therapy. You can talk there."
Correct Answer: A
Rationale: The correct answer is A because it demonstrates active listening and shows empathy towards the patient, which can help them feel heard and understood. By inviting the patient to express their feelings and concerns, the nurse can help de-escalate the situation by addressing the underlying issues.
Choice B is incorrect because it may come across as confrontational and could further provoke the patient's aggression. Choice C is also incorrect as it threatens the patient with consequences, which can escalate the situation. Choice D is not appropriate as it distracts from addressing the current issue of aggression and may not be well-received by the patient in that moment.
An appropriate intervention for a patient with situational low self-esteem would be:
- A. Providing large muscle activities to relieve stress
- B. Attempting to determine triggers to hallucinations
- C. Engaging patient in activities designed to permit success
- D.
Encouraging verbalization of feelings in a safe environment
Correct Answer: C
Rationale: The correct answer is C because engaging the patient in activities designed to permit success helps boost self-esteem by providing opportunities for achievement. This intervention focuses on building the patient's confidence and self-worth through positive experiences. Choice A is incorrect as it addresses stress relief rather than self-esteem. Choice B is irrelevant as it pertains to hallucinations, not self-esteem. Choice D is also incorrect because while verbalizing feelings is important, it may not directly target the underlying issue of low self-esteem.
According to Maslow’s hierarchy of needs, which nursing strategies would assist in meeting self-esteem needs of elderly patients?
- A. Providing privacy when spouses are visiting
- B. Arranging for the spouses to dine with the patients when visiting
- C. Including both the patients and spouses in all educational sessions
- D. Attending to patient hygiene and dress in preparation for spousal visits
Correct Answer: D
Rationale: Step-by-step rationale for why choice D is correct:
1. Maslow's hierarchy of needs places self-esteem as a fundamental psychological need.
2. Patient hygiene and dress contribute to self-esteem by promoting a sense of dignity and self-worth.
3. Attending to hygiene and dress before spousal visits shows respect for the patient's self-esteem.
4. This strategy directly addresses the self-esteem needs of elderly patients by enhancing their sense of self-worth and respect.
Summary of why other choices are incorrect:
A: Providing privacy for spouses does not directly address the patient's self-esteem needs.
B: Arranging dining with spouses may enhance social needs but not directly address self-esteem.
C: Including patients and spouses in educational sessions may promote social interaction but does not directly target self-esteem needs.
The common element seen in every type of bereavement is:
- A. Bereavement is a predictable process that is a result of loss.
- B. The individual has experienced the loss of something of importance.
- C. Acute depression is generally experienced by all who grieve for a loss.
- D. Yearning or longing for the deceased
Correct Answer: B
Rationale: The correct answer is B because it captures the essence of bereavement - the experience of loss. This choice acknowledges that bereavement involves losing something significant, which is a universal aspect of grieving. Other choices are incorrect - A is not always predictable, C is not always acute depression, and D focuses on a specific aspect of grief rather than the core element of loss. Therefore, B is the most comprehensive and inclusive choice.