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Which intervention should the nurse plan to reduce the patient's focus on delusional thinking?
- A. Confronting the delusion
- B. Refuting the delusion with logic
- C. Exploring reasons the patient has the delusion
- D. Focusing on feelings suggested by the delusion
Correct Answer: D
Rationale: The correct answer is D because focusing on the feelings suggested by the delusion can help the patient process and manage their emotions underlying the delusion. By addressing the emotions, the nurse can help the patient gain insight into the delusion and reduce its intensity. Confronting the delusion (A) may lead to resistance and reinforcement. Refuting the delusion with logic (B) may further alienate the patient. Exploring reasons for the delusion (C) may not directly address the emotional component.
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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.
In response to the nurse’s statement, “Tell me about your family,” the patient became silent and displayed nonverbally that he is uncomfortable. Which statement by the nurse reflects sensitivity to the patient?
- A. “I’m so sorry. I didn’t realize your family was a problem for you.”
- B. “Learning to express negative feelings will assist you in getting well.”
- C. “Perhaps you can talk about your feelings to the physician next time you meet.”
- D. “That seems to be a difficult subject for you. We can discuss when you are
Correct Answer: D
Rationale: The correct answer is D because it acknowledges the patient's discomfort without making assumptions or judgments. By recognizing the difficulty the patient is facing and offering to discuss it when they are ready, the nurse shows empathy and respect for the patient's feelings.
Choice A is incorrect because it assumes the family is a problem for the patient. Choice B is incorrect because it focuses on expressing negative feelings rather than addressing the patient's current discomfort. Choice C is incorrect because it deflects the conversation to the physician without addressing the patient's immediate needs.
A nurse is using Piaget’s model to assess a child’s developmental stage. Which behaviors would determine that a child is successfully achieving the skills required of the formal operations level of development? (Select all that apply.)
- A. Becomes sad when the family pet dies.
- B. Plans a trip to attend a basketball game.
- C. Identifies two different bowls that hold 1 cup.
- D. Selects the appropriate clothing for a ski trip.
Correct Answer: B, D
Rationale: In Piaget's formal operations stage, children develop abstract thinking, planning abilities, and logical reasoning. Planning a trip and selecting appropriate clothing demonstrate these skills. Becoming sad over the pet's death and identifying objects by capacity are more related to emotional and concrete operational stages.
Discharge planning begins for an elderly patient hospitalized for 2 weeks diagnosed with major depression. The patient needs ongoing assessment and socialization opportunities as well as education about medication and relapse prevention. The patient lives with a daughter, who works during the week. Select the best referral for this patient.
- A. Behavioral health home care
- B. Partial hospitalization
- C. A skilled nursing facility
- D. A halfway house
Correct Answer: A
Rationale: The correct answer is A: Behavioral health home care. This option provides ongoing assessment, socialization opportunities, and education about medication and relapse prevention, which are all essential for the elderly patient with major depression. Additionally, it allows the patient to stay in their own home environment, promoting comfort and familiarity.
Option B: Partial hospitalization may not provide the ongoing support and socialization opportunities needed for the patient.
Option C: A skilled nursing facility may offer medical care but may not focus on mental health needs or socialization.
Option D: A halfway house is typically for individuals transitioning from addiction treatment and may not address the specific needs of an elderly patient with major depression.
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.