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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.
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Immediately after electroconvulsive therapy, in which position should a nurse place the client?
- A. On his or her side to prevent aspiration.
- B. In semi-Fowlers position to promote oxygenation
- C. In Trendelenburg’s position to promote blood flow to vital organs
- D. In prone position to prevent airway blockage
Correct Answer: A
Rationale: Immediately after ECT, the patient may still be recovering from the effects of muscle relaxants and the seizure. Positioning the client on their side helps prevent aspiration in case of vomiting and maintains an open airwa
Which activity therapy should the nurse recommend to the treatment team to assist the patient to relieve tension and achieve increased body awareness?
- A. Music therapy
- B. Dance therapy
- C. Recreation
- D. Relaxation exercises
Correct Answer: B
Rationale: Dance therapy is a form of activity therapy that uses movement and dance to promote emotional, social, cognitive, and physical integration and well-being. It can help individuals relieve tension, connect with their bodies, and increase body awareness. Through dancing, patients can release emotions, express themselves non-verbally, and improve their overall sense of well-being. Additionally, dance therapy can also help improve muscle tone, coordination, and flexibility, thereby contributing to physical health. Overall, dance therapy can be a beneficial intervention to assist the patient in relieving tension and achieving increased body awareness.
By discharge, which outcome is appropriate for a patient who hears voices telling them they are evil?
- A. Respond verbally to the voices.
- B. Verbalize the reason the voices say they are evil
- C. Identify events that increase anxiety and promote hallucinations.
- D. Integrate the voices into their personality structure in a positive manner.
Correct Answer: C
Rationale: Identifying triggers for hallucinations is a key step in managing symptoms effectively
What milieu factor would need most attention from the nurse who is caring for a patient who has received six ECT treatments and has two more sc\
- A. Therapeutic activities
- B. Boundary maintenance
- C. Safety
- D. Trust attainment
Correct Answer: C
Rationale: When caring for a patient who has received multiple electroconvulsive therapy (ECT) treatments and has more scheduled, the most critical milieu factor that needs attention is safety. ECT is a medical procedure that involves inducing seizures through electrical stimulation, and patients may be at risk of physical harm during or after the treatments. The nurse should prioritize ensuring the patient's safety during and after the ECT sessions, including monitoring for any adverse effects, providing support, and taking necessary precautions to prevent accidents. Safety measures, such as fall prevention protocols and close observation, are essential in the care of patients undergoing ECT to ensure their well-being. Therefore, safety is the milieu factor that requires the most attention in this situation.
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.