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When a hospitalized patient dies, his wife stares blankly at the nurse and states, “It can’t be.” The nurse assesses this as indicating:
- A. Shock and disbelief
- B. Anger and hostility
- C. Disorganization and confusion
- D. Despair and protest.
Correct Answer: A
Rationale: The wife's statement, "It can't be," indicates that she is experiencing shock and disbelief at the news of her husband's death. This response is common when individuals are faced with a sudden and unexpected loss. The wife's blank stare and statement suggest that she is struggling to accept the reality of the situation, which aligns with the symptoms of shock and disbelief.
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In the ECT treatment preparation period the morning of treatment, the nurse should:
- A. Assess the patient’s cognitive function.
- B. Have the patient exercise for 10 minutes.
- C. Ensure that the patient produces a urine sample.
- D. Allow the patient to eat a heavy meal if they are hungry.
Correct Answer: A
Rationale: The correct action during the ECT treatment preparation period the morning of treatment is to adequately hydrate the patient. Ensuring that the patient is properly hydrated before the procedure is crucial for their safety and well-being. Hydration helps optimize the effects of the treatment and can support the patient's recovery post-treatment. It is important to maintain the patient's fluid balance as ECT can sometimes cause side effects such as nausea, headache, and muscle aches, which can be worsened if the patient is not adequately hydrated. Additionally, hydration can help prevent complications such as dehydration or electrolyte imbalances during and after the ECT procedure.
When differentiating between bereavement symptoms and depression, the nurse will base the formulation on knowledge that in bereavement:
- A. Suicide thoughts are common.
- B. Symptoms remit and exacerbate.
- C. Guilt feelings are overwhelming.
- D. Psychomotor retardation is obvious.
Correct Answer: B
Rationale: Bereavement involves waves of emotional pain, often triggered by reminders of the loss, whereas depression typically causes persistent symptoms such as guilt or hopelessness.
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 patient’s sadness and recent significant losses (spouse and friend) put them at risk for depression and suicidal ideation. The nurse should assess for suicidal thoughts and behaviors.
Which statement would the nurse use to describe the primary purpose of boundaries?
- A. Boundaries define responsibilities and duties to one’s self in relation to others.
- B. Boundaries determine objectives of the various working stage of the relationship.
- C. Boundaries differentiate the assumed roles of both the nurse and of the patient.
- D. Boundaries prevent undesired material from emerging during the interaction.
Correct Answer: A
Rationale: Boundaries define responsibilities and duties to one’s self in relation to others. Setting boundaries is essential in establishing a safe and professional therapeutic relationship between a nurse and a patient. These boundaries help to create a clear understanding of each person's roles and responsibilities within the relationship. Boundaries also help protect both the nurse and the patient from potential harm, maintain professionalism, and ensure effective communication and focus on the therapeutic goals. By defining these boundaries, the nurse can better maintain appropriate relationships with patients and avoid conflicts of interest or ethical dilemmas.
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 ill husband
- D. Who attended a bereavement group, where she learned to express feelings after the deaths of her twin daughters
Correct Answer: A
Rationale: The patient whose 16-year-old daughter was raped and killed while going on an errand for the patient would be determined to be at highest risk for dysfunctional grief. This traumatic event involves sudden and violent loss of a child, which can lead to complicated or dysfunctional grief reactions. The circumstances of the death, involving violence, unexpectedness, and the close relationship with the deceased, can significantly impact the grieving process. The patient may struggle with intense emotions, guilt, anger, and unresolved trauma, making them more vulnerable to experiencing dysfunctional grief. It is essential for healthcare professionals to provide appropriate support and interventions to help the patient navigate through this complex grieving process.