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Which intervention will the nurse planning care for a patient with acute grief implement?a. Providing information about the grief process
- A. Providing information about the grief process.
- B. Suggesting utilization of community resources in a few weeks
- C. Encouraging dependence on the nurse for support
- D. Assessing for signs of complicated grief or depression
Correct Answer: A
Rationale: The correct answer is A because providing information about the grief process helps the patient understand their feelings and reactions, promoting emotional healing. Choice B is incorrect because suggesting community resources may not address the patient's immediate needs. Choice C is incorrect as encouraging dependence on the nurse may hinder the patient's ability to cope independently. Choice D is incorrect because assessing for complicated grief or depression is important but not the initial intervention in planning care for acute grief.
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A 79-year-old white male tells a nurse, “I have felt very sad lately. I do not have much to live for. My family and friends are all dead, and my own health is failing.” The nurse should analyze this comment as:
- A. Normal pessimism of the elderly.
- B. A call for sympathy
- C. Evidence of risks for suicide.
- D. Normal grieving.
Correct Answer: C
Rationale: The correct answer is C: Evidence of risks for suicide. The statement contains indicators such as feeling very sad, lack of purpose, isolation, and declining health, which are red flags for suicide risk in older adults. It is crucial for healthcare providers to assess and intervene promptly in such cases to prevent harm. Choices A, B, and D are incorrect because they do not address the seriousness of the situation or the potential risk for self-harm.
Which action will best facilitate the development of trust between a nurse and patient?
- A. Responding positively to the patient’s demands
- B. Clarifying with the patient whenever there is doubt
- C. Staying available to the patient for the entire shift
- D. Following through with whatever was promised
Correct Answer: B
Rationale: The correct answer is B, clarifying with the patient whenever there is doubt. This action shows active listening, respect, and a willingness to understand the patient's needs. By seeking clarification, the nurse demonstrates genuine interest in the patient's perspective, which helps build trust. Responding positively to demands (A) may not always be appropriate or feasible. Staying available for the entire shift (C) is important but not the sole factor in trust-building. Following through with promises (D) is crucial but does not address the patient's concerns or doubts directly. Clarifying doubts fosters clear communication and mutual understanding, establishing a foundation of trust.
The spouse of a patient recently diagnosed with early-stage Alzheimer's disease asks, "Is there anything I can do to help delay the progression of this disease?" Which strategy has the greatest potential for preserving the protective abilities of immune cells related to the disease?
- A. Minimize contact with the public during cold and flu season.
- B. Enroll the patient in an exercise program that meets regularly.
- C. Provide supplements to enhance the patient’s immune system.
- D. Identify creative ways to keep the patient mentally challenged.
Correct Answer: B
Rationale: The correct answer is B: Enroll the patient in an exercise program that meets regularly. Regular exercise has been shown to have numerous benefits for brain health, including improving cognitive function and reducing the risk of cognitive decline. Exercise also helps in maintaining a healthy immune system by promoting the circulation of immune cells throughout the body. This can help support the protective abilities of immune cells related to Alzheimer's disease.
Minimizing contact with the public during cold and flu season (Choice A) may reduce the risk of infections but does not directly address immune cell function. Providing supplements to enhance the patient's immune system (Choice C) may not be supported by scientific evidence and can potentially have adverse effects. Identifying creative ways to keep the patient mentally challenged (Choice D) is beneficial for cognitive health but does not directly target immune cell function as effectively as regular exercise.
Which assessment observation supports a patient’s diagnosis of disorganized schizophrenia?
- A. Reports suicidal ideations
- B. Last relapse was 6 years ago
- C. Consistent inappropriate laughing
- D. Believes that the government is out to get me
Correct Answer: C
Rationale: The correct answer is C because consistent inappropriate laughing is a characteristic symptom of disorganized schizophrenia. This observation aligns with the disorganized behavior and affect commonly seen in this subtype of schizophrenia. Option A is not specific to disorganized schizophrenia. Option B does not directly relate to disorganized symptoms. Option D suggests paranoia, which is more indicative of paranoid schizophrenia rather than disorganized schizophrenia.
A community health nurse visits an elderly person whose spouse died 6 months ago. Two vodka bottles are in the trash. When the nurse asks about alcohol use, this person says, “I get lonely and drink a little to help me forget.” Select the nurse’s most therapeutic intervention.
- A. Assess whether this patient is drinking and driving.
- B. Teach the person about risks for alcoholism and suggest other coping strategies
- C. Advise the person not to drink alone because the risks for injury increase.
- D. Arrange for the person to attend an Alcoholics Anonymous meeting for older adults.
Correct Answer: B
Rationale: The correct answer is B: Teach the person about risks for alcoholism and suggest other coping strategies. This intervention is the most therapeutic because it addresses the underlying issue of using alcohol as a coping mechanism for loneliness and grief. By educating the person about the risks of alcoholism, the nurse can help the individual understand the potential harm of their current coping strategy. Additionally, suggesting alternative coping strategies can provide healthier ways to deal with loneliness and grief, ultimately promoting better overall well-being.
Choice A is incorrect because while assessing drinking and driving is important, it does not directly address the underlying emotional reasons for the alcohol use.
Choice C is incorrect as it focuses on the risks of injury rather than addressing the emotional aspects of the person's drinking behavior.
Choice D is incorrect as it jumps to a specific intervention without first addressing the person's understanding of their alcohol use and providing alternative coping strategies.