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When a nurse overhears the spouse of a patient threaten to 'smack you good if you don't shut up' while sitting in the unit's dayroom, which action reflects the most immediate, therapeutic nursing intervention?
- A. Notify hospital security immediately that the situation exists!
- B. Tell the spouse, 'Your presence is no longer permitted on the unit.'
- C. Ask the patient if the spouse has ever engaged in physically abusive behavior.
- D. Tell the spouse, 'The police will be called unless you leave immediately.'
Correct Answer: A
Rationale: The correct answer is A: Notify hospital security immediately that the situation exists. This is the most immediate, therapeutic nursing intervention because the safety of the nurse, patient, and others in the unit is the top priority. By involving hospital security, the nurse can ensure a swift and appropriate response to the threatening behavior. This action helps to de-escalate the situation and protect everyone involved.
The other choices are incorrect because:
B: Asking the spouse to leave the unit could escalate the situation further and put the nurse at risk.
C: Asking the patient about the spouse's behavior may not be immediate enough to address the threat.
D: Threatening to call the police could escalate the situation and may not be the best approach to ensure safety for all parties involved.
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A victim of partner abuse, parent of one child, describes the partner as someone who is easily frustrated and more likely to be abusive after experiencing an event in which self-esteem is challenged. The most recent episodes of violence were related to feeling "upset"Â over a job loss. What type of therapy would provide the greatest help to the abuser?
- A. Voluntary individual or group therapy
- B. Court-ordered individual or group therapy
- C. Voluntary couples or family therapy
- D. Court-ordered couples or family therapy
Correct Answer: A
Rationale: The correct answer is A: Voluntary individual or group therapy. This type of therapy would provide the greatest help to the abuser because it focuses on addressing the underlying issues of frustration, self-esteem challenges, and abusive behavior. The key here is that the therapy is voluntary, which means the abuser is more likely to engage and actively participate in the process. In individual or group therapy, the abuser can explore and work on managing emotions, coping strategies, and developing healthier communication skills. Court-ordered therapy (choices B and D) may not be as effective because it could be seen as a punishment rather than a genuine effort to seek help. Couples or family therapy (choice C) may not be appropriate initially as the focus should be on the abuser's personal growth and behavior change.
A 76-year-old is regressed, indifferent, and responds to others only when they initiate an interaction. What form of group therapy would be most useful to promote resocialization?
- A. Remotivation
- B. Activity group
- C. Psychotherapy
- D. Reminiscence (life review)
Correct Answer: A
Rationale: Remotivation therapy helps to resocialize regressed and apathetic patients by focusing on a single topic, creating a bridge to reality as group members talk about the world in which they live and work and hobbies related to the topic. Group leaders give members acceptance and appreciation. Group psychotherapy would not be effective for this patient. An activity group does not address the patients problem.
The affective losses of Alzheimer's disease refer to losses noticed in the individual's:
- A. Personality
- B. Thought processes
- C. Ability to make and carry out plans
- D. Self-care
Correct Answer: A
Rationale: The affective losses of Alzheimer's disease refer to changes in emotions and mood, impacting personality traits. This is because the disease affects areas of the brain responsible for regulating emotions. Personality changes are commonly observed in individuals with Alzheimer's. Thought processes (choice B) are more related to cognitive decline, while ability to make and carry out plans (choice C) and self-care (choice D) are more associated with functional decline. Therefore, choice A is correct as it specifically addresses the affective aspect of the disease.
The nurse reports to the interdisciplinary team that an antisocial patient lies to other patients, verbally abuses a patient with Alzheimer's disease, flatters his primary nurse, and is detached and superficial during counseling sessions. Which behavior should be the priority focus of limit setting?
- A. Lying to other patients
- B. Flattering the nursing staff
- C. Verbally abusing other patients
- D. Superficiality during counseling
Correct Answer: C
Rationale: The priority focus of limit setting should be on verbally abusing other patients (Choice C) because it directly harms others and creates a hostile environment. This behavior is not only detrimental to the well-being of other patients but also disrupts the therapeutic milieu. Limiting this behavior is crucial to ensure the safety and emotional health of all patients in the care setting. Lying to other patients (Choice A), flattering the nursing staff (Choice B), and being superficial during counseling sessions (Choice D) are concerning behaviors as well, but they do not pose an immediate risk to the safety and well-being of others in the same way that verbal abuse does. It is important to address all inappropriate behaviors, but the priority should be given to the behavior that has the most significant negative impact on the therapeutic environment.
What is a key consideration when treating a patient with anorexia nervosa?
- A. Addressing the patient's weight first and foremost.
- B. Focusing on nutrition and caloric intake without addressing underlying issues.
- C. Addressing the psychological and emotional factors that contribute to the disorder.
- D. Providing strict dietary restrictions to help the patient regain control over food.
Correct Answer: C
Rationale: The correct answer is C because addressing the psychological and emotional factors is crucial in treating anorexia nervosa. This disorder is not solely about weight or food intake; it often involves deeper psychological issues such as body image distortion, low self-esteem, and control issues. By focusing on the underlying psychological and emotional factors, therapists can help patients understand and cope with these issues, leading to more effective and sustainable recovery. Choices A, B, and D are incorrect because they overlook the complexity of anorexia nervosa and may even exacerbate the patient's condition by neglecting the root causes of the disorder.