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When assessing the elderly for depression, the nurse may find that a depressed person over 70 years of age without a medical diagnosis, may have the following symptoms of depression (Select one tha does not apply):
- A. Aches
- B. Pains
- C. Constipation
- D. One-sided weakness
Correct Answer: D
Rationale: These symptoms (A, B, C, E) can be confused with other conditions like electrolyte imbalance or dementia, but are common physical manifestations of depression in the elderly. One-sided weakness (D) is more specific to stroke, not depression.
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A patient, aged 77 years, has Alzheimer's disease. She goes to day care during the week and is otherwise cared for by her daughter and grandchildren. The nurse at the day care center noticed multiple bruises on the patient's palms, elbows, and buttocks. When the daughter arrived to pick her up, the nurse discussed her observations. The daughter became defensive and said that her mother was very difficult to manage. She stated, "My mother is not my mother anymore. She is confused, and she wanders all night. We have to watch her constantly. Last night I fell asleep, and she fell down the stairs. Sometimes she cannot recognize me and accuses me of trying to poison her. I can't concentrate at work, and it's wrecking the family. Sometimes I just cannot bear it."Â Which nursing diagnosis would be most important to address for this family?
- A. Knowledge deficit pertaining to dementia
- B. Grieving related to mother's deterioration
- C. Risk for injury related to cognitive impairment
- D. Caregiver role strain related to increased care needs
Correct Answer: D
Rationale: The correct nursing diagnosis to address in this scenario is D: Caregiver role strain related to increased care needs. This is the most important as it focuses on the daughter's challenges and emotional burden due to her mother's condition. The daughter's statements reveal feelings of overwhelm, guilt, and exhaustion, which are key indicators of caregiver role strain. By addressing this nursing diagnosis, the healthcare team can provide support and resources to help the daughter cope with the demands of caring for her mother.
Choice A (Knowledge deficit pertaining to dementia) is not the most important in this situation as the daughter's issue is not lack of knowledge but rather emotional stress. Choice B (Grieving related to mother's deterioration) is not the priority as addressing the daughter's emotional strain is more urgent than addressing grief. Choice C (Risk for injury related to cognitive impairment) is also important but not as immediate as addressing the caregiver's emotional well-being.
Which of the following is a common emotional response for patients with anorexia nervosa?
- A. Fear of gaining weight and loss of control over eating.
- B. Lack of concern about food intake and weight.
- C. Excessive joy and pride in achieving weight loss.
- D. Denial of the need for treatment and weight restoration.
Correct Answer: A
Rationale: The correct answer is A because fear of gaining weight and loss of control over eating are core features of anorexia nervosa. Patients with anorexia often have an intense fear of gaining weight, leading to restrictive eating behaviors. This fear is accompanied by a sense of loss of control over their eating habits.
Choice B is incorrect because lack of concern about food intake and weight is not a common emotional response in anorexia nervosa. Choice C is incorrect as excessive joy and pride in achieving weight loss are more characteristic of other eating disorders like bulimia nervosa or orthorexia. Choice D is incorrect because denial of the need for treatment and weight restoration may be present in some cases but is not a common emotional response in anorexia nervosa.
Which statement by a parent of a teen with anorexia nervosa suggests a need for further education?
- A. I will make sure my teen eats three meals a day.
- B. It is important to monitor my teen's weight regularly.
- C. I should encourage my teen to keep a food journal.
- D. I should allow my teen to skip meals if she feels full.
Correct Answer: D
Rationale: The correct answer is D because allowing the teen to skip meals if she feels full can reinforce unhealthy eating behaviors associated with anorexia nervosa. This statement contradicts the essential goal of promoting regular and adequate meal intake to support recovery. Encouraging the teen to eat when not hungry may be necessary to restore normal eating patterns. Choices A, B, and C align with supporting the teen's nutritional needs and recovery process.
A patient is currently in an abusive relationship with the father of her only child and tells a nurse that her partner 'is really sorry for hitting me and wants to come back and be part of the family again.' The nurse should provide which intervention?
- A. Share with the patient that abusers seldom voluntarily stop abusing.
- B. Identify groups that focus on treatment for individuals who are abusive.
- C. Tell the patient to continue the relationship, but focus on how to minimize the abuse.
- D. Tell the patient's partner that any continued abuse will be reported to the police.
Correct Answer: B
Rationale: The correct answer is B: Identify groups that focus on treatment for individuals who are abusive. This intervention is appropriate because it addresses the root cause of the abusive behavior, which is the partner's abusive tendencies. By connecting the abuser to groups that specialize in treating abusive behavior, there is a chance for change and rehabilitation.
A: Sharing with the patient that abusers seldom voluntarily stop abusing may not be helpful as it does not provide a proactive solution to address the abusive behavior.
C: Telling the patient to continue the relationship and focus on minimizing the abuse is dangerous as it normalizes and enables the abusive behavior, putting the patient at further risk.
D: Threatening the patient's partner with reporting to the police may escalate the situation and put the patient at higher risk of harm. It does not address the underlying issue of the partner's abusive behavior.
The client has been taking lithium and fluoxetine (Prozac) for almost a week. During today's assessment, the nurse notes a temperature of 39°C, muscle rigidity, and confusion. The client's signs and symptoms suggest:
- A. Dystonic reactions
- B. Bradykinesic side effects
- C. Extrapyramidal side effects
- D. Neuroleptic malignant syndrome
Correct Answer: D
Rationale: The correct answer is D: Neuroleptic malignant syndrome (NMS). This is indicated by the client's elevated temperature, muscle rigidity, and confusion, which are classic symptoms of NMS. NMS is a serious, potentially life-threatening condition associated with the use of antipsychotic medications like lithium and fluoxetine. The onset of NMS is often rapid and can lead to severe complications if not treated promptly. Dystonic reactions (choice A) involve sudden and involuntary muscle contractions, which are not consistent with the client's symptoms. Bradykinesic side effects (choice B) refer to slowed movements, which are not present in this case. Extrapyramidal side effects (choice C) typically include symptoms like tremors, stiffness, and restlessness, but do not encompass the combination of symptoms seen in NMS.