Nokea
When making a distinction as to whether an elderly patient has confusion related to delirium or another problem, what information would be of particular value?
- A. Evidence of spasticity or flaccidity
- B. Medications the patient has recently taken.
- C. Level of preoccupation with somatic symptoms
- D. The patient’s level of motor activity
Correct Answer: B
Rationale: The correct answer is B: Medications the patient has recently taken. This is crucial because certain medications can cause delirium in elderly patients. Step 1: Evaluate recent medication history. Step 2: Identify medications known to cause delirium. Step 3: Determine if the patient has taken any of these medications. Other choices are incorrect because: A: Evidence of spasticity or flaccidity is more related to neuromuscular conditions. C: Level of preoccupation with somatic symptoms is not specific to delirium assessment. D: The patient’s level of motor activity is not a key factor in distinguishing delirium from other problems.
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A teen states, "I miss my dog so much, but if I start crying, I will never stop." This reflects a fear of:
- A. Losing control over her emotions
- B. Losing the support of her friends and family
- C. Embarrassing herself by crying in public
- D. Appearing emotionally immature
Correct Answer: A
Rationale: The correct answer is A because the teen is expressing a fear of losing control over her emotions if she starts crying. This is evident from her belief that she will never stop crying once she starts. Option B (Losing the support of her friends and family) is incorrect as the statement does not suggest concern about losing support. Option C (Embarrassing herself by crying in public) is incorrect as the fear expressed is more about not being able to stop crying rather than embarrassment. Option D (Appearing emotionally immature) is incorrect as there is no indication that the teen is worried about how others perceive her emotional maturity.
An appropriate intervention for a patient with situational low self-esteem would be:
- A. Providing large muscle activities to relieve stress
- B. Attempting to determine triggers to hallucinations
- C. Engaging patient in activities designed to permit success
- D.
Encouraging verbalization of feelings in a safe environment
Correct Answer: C
Rationale: The correct answer is C because engaging the patient in activities designed to permit success helps boost self-esteem by providing opportunities for achievement. This intervention focuses on building the patient's confidence and self-worth through positive experiences. Choice A is incorrect as it addresses stress relief rather than self-esteem. Choice B is irrelevant as it pertains to hallucinations, not self-esteem. Choice D is also incorrect because while verbalizing feelings is important, it may not directly target the underlying issue of low self-esteem.
What is the priority nursing diagnosis for a catatonic patient?
- A. Ineffective coping
- B. Impaired physical mobility
- C. Risk for deficient fluid volume
- D. Impaired social interaction
Correct Answer: C
Rationale: The priority nursing diagnosis for a catatonic patient is Risk for deficient fluid volume (C) because catatonic patients are at risk for dehydration due to decreased fluid intake or inability to meet fluid needs. This diagnosis takes precedence over others as dehydration can lead to serious complications. Ineffective coping (A) may be secondary to the catatonic state but addressing fluid volume is more urgent. Impaired physical mobility (B) and Impaired social interaction (D) are important but not as critical as addressing the risk of dehydration in a catatonic patient.
What is the primary reason for the nurse to have an understanding of the various types of activity and adjunct therapies?
- A. The nurse chooses the most cost-effective therapy group.
- B. The nurse is expected to encourage patients’ involvement in the therapies.
- C. The nurse is responsible for placing the patient in the appropriate group.
- D. The nurse needs to be supportive of the treatment team members who direct these therapies.
Correct Answer: B
Rationale: The correct answer is B because nurses are expected to encourage patients' involvement in therapies to promote holistic care and enhance patient outcomes. By understanding different types of therapies, nurses can educate and motivate patients to participate actively in their treatment plans. This empowers patients to take control of their health and improve their overall well-being. Choices A, C, and D are incorrect because the primary role of the nurse in this context is to support and advocate for the patients' engagement in therapies, rather than focusing on cost-effectiveness, placement, or support of other team members.
A nurse administers pure oxygen to a client during and after electroconvulsive therapy. What is the nurse’s rationale for this procedure?
- A. To prevent increased intracranial pressure resulting from anoxia
- B. To prevent anoxia due to medication-induced paralysis of respiratory muscles
- C. To prevent hypotension, bradycardia, and bradypnea due to electrical stimulation
- D. To prevent blocked airway resulting from seizure activity
Correct Answer: B
Rationale: The correct answer is B: To prevent anoxia due to medication-induced paralysis of respiratory muscles. During electroconvulsive therapy, muscle relaxants are often used to prevent injury during the seizure. These medications can lead to paralysis of respiratory muscles, causing potential anoxia if oxygen is not administered. Providing pure oxygen ensures adequate oxygenation despite muscle paralysis.
Incorrect Choices:
A: Preventing increased intracranial pressure is not the primary rationale for administering oxygen during ECT.
C: Hypotension, bradycardia, and bradypnea are potential side effects of ECT itself, but oxygen administration is not primarily to prevent these.
D: Oxygen is not administered to prevent a blocked airway but rather to ensure adequate oxygenation during muscle paralysis.