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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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During a grief-processing group, an elderly patient stated, “For the first time since my husband died, I’m having more good days than bad.” This statement suggests that the patient has:
- A. Reached the phase of reestablishment
- B. Determined she is ready to terminate the support group
- C. Completed her “grief work” successfully
- D. Replaced old memories with new ones.
Correct Answer: C
Rationale: The correct answer is C: Completed her "grief work" successfully. This statement indicates progress in the grieving process, moving towards acceptance and healing. The patient acknowledging having more good days than bad reflects a positive shift in coping with the loss, indicating that she has processed her grief and is beginning to adapt to life without her husband. This suggests that the patient has worked through her emotions, memories, and adjustments related to the loss, reaching a point where she is experiencing more peace and acceptance.
Summary:
A: Reestablishment is not the correct choice as it does not specifically address the completion of the grief work.
B: Determining readiness to terminate the support group is premature, as the patient may still benefit from continued support.
D: Replacing old memories with new ones is not supported by the patient's statement and does not necessarily indicate successful grief processing.
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.
The patient states, "Everybody picks on me. They frobitz me." The patient’s communication exhibits:
- A. A neologism
- B. Loose associations
- C. Delusional thinking
- D. Circumstantial speech
Correct Answer: A
Rationale: The correct answer is A: A neologism. A neologism is a made-up word or phrase that only has meaning to the individual. In this case, "frobitz" is not a known word in the English language, indicating a neologism. This suggests possible language or thought disorder. B: Loose associations involve disconnected or tangential thoughts. C: Delusional thinking involves fixed false beliefs. D: Circumstantial speech includes excessive, irrelevant detail before reaching the main point.
The desired outcome for a patient experiencing insomnia is, "Patient will sleep for a minimum of 5 hours nightly within 7 days." At the end of 7 days, review of sleep data shows the patient sleeps an average of 4 hours nightly and takes a 2-hour afternoon nap. The nurse will document the outcome as:
- A. Consistently demonstrated.
- B. Often demonstrated.
- C. Sometimes demonstrated
- D. Never demonstrated.
Correct Answer: C
Rationale: The correct answer is C: Sometimes demonstrated. The rationale is that the patient is not consistently meeting the desired outcome of sleeping for a minimum of 5 hours nightly within 7 days. Although the patient is sleeping for an average of 4 hours nightly, the 2-hour afternoon nap indicates that the patient is not achieving the desired outcome consistently. Therefore, the nurse would document the outcome as "Sometimes demonstrated" to reflect that the patient is making progress towards the goal but has not fully achieved it. Choices A, B, and D are incorrect because the patient's sleep behavior does not align with being consistently, often, or never demonstrated based on the desired outcome criteria.
Which statement best explains how a mother of several children should prepare to help them cope with the loss of a dear aunt?
- A. Each child will grieve in a unique way and on their own timetable
- B. Children are resilient and simply need love as they grieve.
- C. People regardless of age or gender experience stages of grief.
- D. Extreme reactions are more commonly observed in the young griever
Correct Answer: A
Rationale: The correct answer is A because each child will indeed grieve in a unique way and on their own timetable. This approach recognizes the individuality of each child's emotions and coping mechanisms. By understanding and respecting their differences, the mother can provide tailored support and comfort. Option B oversimplifies the grieving process and ignores the complexity of individual responses. Option C generalizes the stages of grief for all people and does not account for variations in how children may process loss. Option D incorrectly suggests that extreme reactions are more common in young children, which is not necessarily true as grief responses can vary widely among children.