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Which intervention best reflects the nursing role regarding effective implementation of behavioral therapy goals?
- A. Administering the prescribed medications accurately
- B. Interacting effectively with members of the health care team
- C. Being aware of all the patient related therapeutic modalities
- D. Evaluating patient behaviors to reward economic tokens appropriately
Correct Answer: D
Rationale: The correct answer is D because evaluating patient behaviors to reward economic tokens appropriately is a key aspect of behavioral therapy. By assessing and reinforcing positive behaviors with rewards, nurses can encourage patients to continue working towards their therapy goals. Administering medications accurately (choice A) is important but not directly related to behavioral therapy goals. Interacting effectively with the health care team (choice B) is important for overall patient care but does not specifically address behavioral therapy. Being aware of therapeutic modalities (choice C) is important but does not directly contribute to implementing behavioral therapy goals like choice D does.
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Which intervention would qualify as primary prevention of violent behaviors in children and adolescents?
- A. Forbidding the child to continue friendships with violent peers
- B. Limiting exposure to violence on TV, video, and computer games
- C. Seeking counseling for a child who has been experimenting with drugs
- D. Showing a unified approach to parenting when dealing with a violent child
Correct Answer: B
Rationale: The correct answer is B because limiting exposure to violence on TV, video, and computer games falls under primary prevention by addressing risk factors before violent behaviors occur. This intervention helps reduce the likelihood of children and adolescents developing violent tendencies by minimizing their exposure to violent content that can influence their behavior.
A: Forbidding the child to continue friendships with violent peers is more of a secondary prevention strategy targeting existing risk factors, not primary prevention.
C: Seeking counseling for a child who has been experimenting with drugs is also a secondary prevention strategy focusing on addressing a specific risk factor, not primary prevention.
D: Showing a unified approach to parenting when dealing with a violent child is a tertiary prevention strategy aimed at managing and reducing harm after the behavior has already occurred, not primary prevention.
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.
A 70-year-old male has the nursing diagnosis of situational low self-esteem related to forced retirement. Using Maslow’s hierarchy, the nurse is confident the patient is meeting self-worth outcomes when the patient:
- A. Moves to a secure apartment building
- B. Exercises regularly with friends at the gym
- C. Attends his grandchildren’s school functions
- D. Volunteers at the local homeless shelter weekly
Correct Answer: D
Rationale: The correct answer is D because volunteering at the local homeless shelter fulfills the self-actualization need in Maslow's hierarchy. By helping others and contributing to the community, the patient gains a sense of purpose and fulfillment, boosting self-esteem.
A: Moving to a secure apartment building addresses safety needs, not self-esteem.
B: Exercising with friends promotes social belonging but does not directly address self-esteem.
C: Attending grandchildren's functions fosters social connections, but it may not directly impact self-esteem like volunteering does.
A patient living in community housing for the elderly says, “I don’t go to the senior citizens club. They play cards and talk about the past because that’s all they can do.” The nurse analyzes these remarks to represent:
- A. Failure to achieve developmental tasks
- B. Hypercritical behavior
- C. Paranoid thinking
- D. Thinking associated with ageism
Correct Answer: D
Rationale: The correct answer is D: Thinking associated with ageism. This is because the patient's statement reflects a negative stereotype about older adults, assuming they are limited to playing cards and reminiscing about the past. Ageism involves discrimination or prejudice based on someone's age, which can lead to stereotyping and marginalization.
A: Failure to achieve developmental tasks - This choice does not directly relate to the patient's statement about ageism.
B: Hypercritical behavior - The patient's statement does not indicate hypercritical behavior, but rather a biased perspective on aging.
C: Paranoid thinking - The patient's statement does not demonstrate paranoid thinking, but rather a biased view of older adults based on ageist beliefs.
In summary, the correct answer is D as the patient's remarks reflect ageist thinking, while the other choices do not align with the content of the patient's statement.
Which statement made by a patient just prior to being transported for a scheduled ECT treatment would result in cancellation of the treatment?
- A. “Will I remember having this treatment?”
- B. “Did eating some crackers cause any problems?”
- C. "Is this going to help me feel better soon?"
- D. "I feel like I need to ask more questions about the procedure."
Correct Answer: A
Rationale: The correct answer is A because asking about memory loss indicates a lack of informed consent and understanding of ECT procedure. Memory loss is a common side effect of ECT, and a patient should be well-informed about it before treatment. Choices B, C, and D do not raise concerns about the patient's understanding or readiness for ECT, making them incorrect. Choice B asks about dietary concerns, which do not directly impact the treatment. Choice C shows the patient's hope for improvement, which is a positive attitude. Choice D indicates the patient's desire for more information, which is a sign of engagement in their care.