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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. The patient’s level of motor activity
- C. Medications the patient has recently taken
- D. Level of preoccupation with somatic symptoms
Correct Answer: C
Rationale: The correct answer is C: Medications the patient has recently taken. This information is crucial because certain medications can cause symptoms of delirium or exacerbate confusion in elderly patients. By reviewing the patient's recent medications, healthcare providers can identify potential drug-induced causes of confusion and adjust the treatment accordingly.
Choice A (Evidence of spasticity or flaccidity) is incorrect because these symptoms are more related to neurological conditions such as stroke or spinal cord injury, not specifically delirium.
Choice B (The patient’s level of motor activity) is not as relevant in distinguishing delirium from other problems as medication history, as motor activity can be influenced by various factors.
Choice D (Level of preoccupation with somatic symptoms) is also less relevant compared to medication history in differentiating delirium, as somatic symptoms may not always directly indicate the underlying cause of confusion in elderly patients.
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When differentiating between bereavement symptoms and depression, the nurse will base the formulation on knowledge that in bereavement:
- A. Symptoms remit and exacerbate.
- B. Guilt feelings are overwhelming.
- C. Suicide thoughts are common.
- D. Psychomotor retardation is obvious.
Correct Answer: A
Rationale: The correct answer is A because in bereavement, symptoms of grief and sadness tend to come and go, known as remitting and exacerbating, as the individual processes the loss over time. This is a normal part of the grieving process. On the other hand, in depression, symptoms are persistent and may not improve without intervention. Guilt feelings being overwhelming (B) is common in both bereavement and depression. Suicide thoughts being common (C) can occur in severe depression but are not a distinguishing factor between bereavement and depression. Psychomotor retardation being obvious (D) is a symptom more commonly associated with severe depression rather than bereavement.
A patient states, "I’m not worth anything. I have negative thoughts about myself. I feel anxious and shaky all the time. Sometimes I feel so sad that I want to go to sleep and never wake up." Which nursing intervention should have the highest priority?
- A. Self-esteem-building activities.
- B. Anxiety self-control measures.
- C. Sleep enhancement activities.
- D. Suicide precautions.
Correct Answer: D
Rationale: The correct answer is D: Suicide precautions. The patient's statement indicates they are experiencing severe depression and suicidal ideation. Suicide precautions should be the highest priority to ensure the patient's safety. This includes removing any potential means of self-harm, constant monitoring, and close supervision. Self-esteem-building activities (A) may be helpful in the long term but are not the immediate priority. Anxiety self-control measures (B) are important but addressing suicidal ideation takes precedence. Sleep enhancement activities (C) are also important but not the highest priority when dealing with suicidal thoughts.
Which person has the greatest potential for developing dysfunctional grief?
- A. A teen who has always been one of the popular kids
- B. A widow who regularly states, I really loved my deceased wife
- C. A woman whose husband died as a result of a sudden, traumatic injury
- D. An adult who has dealt with the loss of several family members over the years
Correct Answer: C
Rationale: The correct answer is C because sudden, traumatic deaths can lead to complicated grief reactions. This type of loss can disrupt the individual's ability to process and accept the death, resulting in prolonged and intense emotional distress. The other choices, A, B, and D, do not inherently indicate a higher potential for dysfunctional grief as they do not involve the same level of suddenness or trauma. Teen popularity, expressing love for a deceased spouse, and experiencing multiple losses over time are common situations that may not necessarily lead to dysfunctional grief if appropriate support and coping mechanisms are in place.
A woman whose abusive husband was killed in an automobile accident 3 years earlier continues to idealize him and repeatedly talks about their “wonderful relationship.” Which outcome is most appropriate for the patient? Patient will:
- A. Enlist the emotional support of both family and friends.
- B. Keep a daily journal recording memories of time spent with her husband.
- C. Express both positive and negative feelings about her husband and their life together.
- D. Read information on the affects of physical abuse and the support groups available to her.
Correct Answer: C
Rationale: Rationale:
Choice C is correct because it encourages the patient to express both positive and negative feelings about her husband and their relationship. This approach helps the patient process complex emotions and move towards a more realistic view of the past. It promotes emotional healing and growth by allowing the patient to acknowledge and work through conflicting feelings.
Summary of Incorrect Choices:
A: While emotional support is important, simply enlisting the support of family and friends may not address the underlying issues of idealization and unresolved emotions.
B: Keeping a daily journal may reinforce the idealization of the husband and could potentially hinder the patient's progress in coming to terms with the reality of the relationship.
D: Reading about abuse and support groups may provide information, but it does not directly address the patient's need to explore and express her own feelings about her husband and their relationship.
Which description is characteristic of an impulsive child?
- A. Running out into the street regardless of frequent instruction to look both ways first.
- B. Pacing and speaking in a very loud, disruptive voice
- C. Frequently talking about hearing voices telling him what to do
- D. Having a difficult time concentrating on reading since his attention is easily diverted
Correct Answer: A
Rationale: The correct answer is A. An impulsive child typically acts without thinking or considering consequences, such as running into the street without looking. This behavior is impulsive, risky, and disregards safety instructions. Choices B and C describe behaviors that are more indicative of other issues like hyperactivity or hallucinations. Choice D suggests difficulty concentrating, which is not directly related to impulsivity. In summary, the key characteristic of an impulsive child is acting quickly without considering potential dangers or instructions.