Nokea
Which activities should the nurse evaluate in an assessment of an older patient’s functional status? (Select all that apply.)
- A. Possessing the ability to prepare nutritious meals independently.
- B. Having the financial resources available to live independently
- C. Performing regular, simple maintenance on their primary residence.
- D. Effectively toileting themselves for both bowel and bladder elimination.
Correct Answer: A,C
Rationale: The correct answers are A and C. A nurse should evaluate if the older patient can prepare nutritious meals independently, as this indicates their ability to meet basic nutritional needs and maintain independence in daily living. Additionally, assessing if the patient can perform regular, simple maintenance on their primary residence is important for gauging their ability to live safely and comfortably. Choices B and D are incorrect as financial resources and toileting abilities, while important, do not directly reflect functional status in the same way as meal preparation and home maintenance.
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Select the best outcome for a patient with the nursing diagnosis: "Impaired social interaction related to sociocultural dissonance as evidenced by stating, 'Although I’d like to, I don’t join in because I don’t speak the language very well.'” Patient will:
- A. Show improved use of language.
- B. Demonstrate improved social skills.
- C. Become more independent in decision-making.
- D. Select and participate in one group activity per day.
Correct Answer: D
Rationale: The correct answer is D: Select and participate in one group activity per day. This outcome directly addresses the nursing diagnosis of impaired social interaction by encouraging the patient to engage in a specific social activity daily. This goal promotes social interaction, helps the patient overcome language barriers, and gradually enhances their social skills. It provides a structured approach to improve the patient's sociocultural integration.
A: Show improved use of language - This choice focuses solely on language skills but does not directly address the social interaction issue.
B: Demonstrate improved social skills - While this choice is related to the nursing diagnosis, it is too broad and lacks specificity compared to choice D.
C: Become more independent in decision-making - This choice is not directly related to addressing impaired social interaction caused by language barriers.
A grief support group is held at the local community center to assist persons who are dealing with issues of loss. Which remark by one of the members would the nurse interpret as indicating unresolved feelings of guilt?
- A. “I know that my husband had a good life.”
- B. “It seems I miss my son more as time goes on.”
- C. “I am still wishing I had gotten help to him sooner.”
- D. "The holidays are always so hard for me now."
Correct Answer: C
Rationale: The correct answer is C because the statement indicates feelings of guilt about not getting help sooner, suggesting the member may blame themselves for the loss. This remark reflects a sense of responsibility and regret, common in unresolved guilt. Choice A expresses acceptance, B reflects natural grief progression, and D highlights difficulty during specific times, not necessarily linked to guilt. By analyzing the content of each statement, the nurse can identify cues related to unresolved feelings of guilt.
When a hospitalized patient dies, his wife stares blankly and states, "It can’t be." This indicates:
- A. Despair and protest
- B. Shock and disbelief
- C. Anger and hostility
- D. Disorganization and confusion
Correct Answer: B
Rationale: Correct Answer: B (Shock and disbelief)
Rationale:
1. The wife's blank stare and statement "It can’t be" suggest a state of disbelief and being stunned by the news of her husband's death, indicating shock.
2. Shock is a common initial reaction to unexpected and distressing events, such as the sudden death of a loved one.
3. This choice is the most fitting based on the wife's reaction of disbelief and being unable to accept the reality of the situation.
Summary:
A: Despair and protest - Despair involves a sense of hopelessness, not evident in the wife's initial reaction. Protest implies a more active response, while the wife's reaction is passive.
C: Anger and hostility - There is no indication of anger or hostility in the wife's initial response; rather, it is characterized by disbelief.
D: Disorganization and confusion - While the wife may feel disorganized and confused later, her initial response reflects more shock and disbelief than disorganization
The nurse is determining whether the patient’s needs could be best met in a task or a process group. The decision is based on the understanding that a task group focuses on:
- A. The “here and now”
- B. Communication styles
- C. Relations among the members
Correct Answer: A
Rationale: The correct answer is A: The "here and now." In a task group, the focus is on addressing specific goals, tasks, and problem-solving in the present moment. This approach helps members work together efficiently to achieve objectives. Communication styles (B) are more relevant in a group focused on improving communication skills. Relations among the members (C) are typically emphasized in a process group, where the focus is on interpersonal dynamics and relationships. Choice D is incomplete and does not align with the purpose of a task group.
Which of the following meets the DSM-IV-TR criteria for moderate mental retardation?
- A. Requires constant one-on-one supervision and total physical care
- B. Advanced as far as the second grade and provides her own personal care with supervision
- C. Attends the local community college for developmental English and math courses
- D. Advanced as far as the sixth grade and works at a warehouse every day and supports himself.
Correct Answer: D
Rationale: The correct answer is D because the DSM-IV-TR criteria for moderate mental retardation includes an IQ range of 35-49, which typically corresponds to functioning at around the level of a 6 to 9-year-old. Choice D best fits this criteria as the individual has advanced to the sixth grade level academically, indicating a level of functioning consistent with moderate mental retardation. Choices A, B, and C do not meet the criteria as they suggest a higher level of functioning and independence than what is typically associated with moderate mental retardation.