Nokea
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 child, aged 11 years, stays home from school to care for his siblings while his mother works, because the family cannot afford a babysitter. The home is cluttered and dirty when the community mental health nurse visits to investigate the child's school absences. The nurse's legal responsibility if child abuse or neglect is suspected is to:
- A. consult with the child's teacher, principal, and school psychologist.
- B. document the observations and impressions in the family health record.
- C. report her suspicions of abuse or neglect according to state regulations.
- D. wait until she has proof of abuse or neglect, then report it to authorities.
Correct Answer: C
Rationale: Correct Answer: C
Rationale:
1. **Legal Obligation**: The nurse has a legal duty to report suspicions of child abuse or neglect.
2. **Protecting the Child**: Reporting ensures the child's safety and well-being.
3. **State Regulations**: State laws mandate reporting suspected abuse or neglect.
4. **Immediate Action**: Waiting for proof delays intervention and puts the child at risk.
Summary:
- Choice A: Consulting with school staff doesn't fulfill the legal obligation to report.
- Choice B: Documenting is important but not sufficient; reporting is crucial.
- Choice D: Waiting for proof is dangerous; immediate reporting is necessary to protect the child.
Select the best comment for a nurse to begin an interview with an elderly patient.
- A. I am a nurse. Are you familiar with what nurses do?
- B. Hello. I am going to ask you some questions to get to know you better.
- C. You look comfortable and ready to participate in an admission interview. Shall we get started?
- D. Hello. My name is_____ and I am a nurse. How you would like to be addressed by staff?
Correct Answer: D
Rationale: The correct answer is D because it establishes the nurse's identity and shows respect by asking the patient's preference for addressing them. This approach sets a positive tone and promotes patient-centered care. Option A is incorrect as it assumes the patient's familiarity with nurses. Option B lacks professionalism and fails to acknowledge the purpose of the interview. Option C assumes the patient's readiness without confirming it directly and may come off as presumptuous.
The mother of a teen with an eating disorder tells the nurse, "Our family is pretty well adjusted. It's hard for me to imagine what we could have done to have this happen."Â The nurse can promote more complete understanding of the etiology of eating disorders by mentioning that young women are also influenced by:
- A. the abundance of nutritious foods available.
- B. the fashion industry's idealization of thinness.
- C. competition in the work place.
- D. the biologic tendency to be underweight.
Correct Answer: B
Rationale: The correct answer is B: the fashion industry's idealization of thinness. This is because the fashion industry often promotes thinness as the ideal body type, leading to societal pressure on young women to conform to this standard. This can contribute to the development of eating disorders as individuals may engage in unhealthy behaviors to achieve or maintain a thin body shape.
A: the abundance of nutritious foods available - While access to nutritious foods is important for overall health, it does not directly influence the development of eating disorders.
C: competition in the work place - While workplace competition may contribute to stress, it is not a primary factor in the development of eating disorders.
D: the biologic tendency to be underweight - While genetic factors can play a role in susceptibility to eating disorders, it is not the primary influence in the development of these disorders in young women.
To help communicate epidemiological trends amongst youth, a family doctor can refer to a typical Secondary School class of 33 students. In explaining to a parent, how many students would you estimate to report clinically significant symptoms of depression in one such class?
- A. 1
- B. 4
- C. 9
- D. 13
Correct Answer: C
Rationale: Using 27% , 27% of 33 ≈ 9 students, aligning with depression prevalence estimates in Singapore youth.
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.