Nokea
Which initial short-term outcome would be appropriate for a patient admitted with delusional thoughts?
- A. Accept that delusion is illogical.
- B. Distinguish external boundaries.
- C. Explain the basis for the delusions.
- D. Engage in reality-oriented conversation.
Correct Answer: D
Rationale: The correct answer is D, engage in reality-oriented conversation. This is appropriate because it helps the patient ground themselves in reality and potentially reduce the intensity of their delusions. By discussing real-life events and situations, the patient is encouraged to recognize the disparity between their delusional thoughts and actual reality. Choice A is incorrect as simply accepting the delusion as illogical does not actively address the patient's condition. Choice B, distinguishing external boundaries, is not as effective in directly challenging the delusional thoughts. Choice C, explaining the basis for the delusions, may not be helpful initially as the patient may not be receptive to logical explanations due to their distorted thinking.
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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
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.
Which response demonstrates both empathy and understanding of the relationship genetics has to the development of schizophrenia in twins?
- A. In fraternal twins, the chance of the other twin developing the disorder is quite small.
- B. No one can say what will happen, so we will hope for the best for you and both of your sons.
- C. You poor woman! I wish I could tell you that your other son will be free of the disorder
- D. Studies show that 50% of twins develop schizophrenia when it is present in the other twin.
Correct Answer: D
Rationale: The correct answer is D because it provides an empathetic response by acknowledging the concern of the parent and demonstrating an understanding of the genetic link between twins and schizophrenia. By citing a specific statistic (50%), it shows knowledge of the relationship between genetics and the development of schizophrenia in twins.
Choice A is incorrect because it downplays the genetic influence by suggesting a small chance, which is not accurate.
Choice B is incorrect because it dismisses the seriousness of the situation and does not address the genetics aspect of the disorder.
Choice C is incorrect because it is not based on factual information and offers sympathy without addressing the genetic component of schizophrenia in twins.
The Omnibus Budget Reconciliation Act (OBRA) provides standards of care for which of the following?
- A. Very young
- B. Older adults
- C. Those who have certain intellectual communication difficulties Those who have certain intellectual communication difficulties
- D. Those without medical insurance
Correct Answer: B
Rationale: The correct answer is B: Older adults. OBRA primarily focuses on setting standards of care for older adults in long-term care facilities, ensuring their safety and well-being. This is because older adults are a vulnerable population requiring specialized care and attention. Choices A, C, and D are incorrect because OBRA does not specifically address very young individuals, those with intellectual communication difficulties, or individuals without medical insurance. The Act mainly pertains to the care and rights of older adults in long-term care settings.
How can the nurse encourage an extremely shy patient to participate therapeutically in a dance activity group?
- A. Offer to dance with the patient.
- B. Ask the patient if this is the first dance he has attended.
- C. Sit with the patient away from the group.
- D. Encourage another patient to ask him to dance.
Correct Answer: A
Rationale: The correct answer is A because offering to dance with the patient shows support, builds trust, and models behavior. This approach can help the shy patient feel more comfortable and encouraged to participate. Choice B focuses on the patient's past experience, which may not directly address the current issue. Choice C isolates the patient, potentially increasing feelings of shyness. Choice D involves a third party, which may not be as effective in building a direct connection with the shy patient. Overall, option A is the most effective in directly engaging and encouraging the shy patient to participate therapeutically in the dance activity group.