Which intervention would be appropriate for a patient with a nursing diagnosis of Ineffective coping as evidenced by manipulation of others?
- A. Refer patient requests and questions about care to the primary nurse.
- B. Provide negative reinforcement for any acting-out behavior.
- C. Ignore rather than confront inappropriate interpersonal behavior.
- D. Encourage the patient to discuss feelings of fear and inferiority.
Correct Answer: A
Rationale: The correct answer is A because referring patient requests and questions about care to the primary nurse promotes patient independence and helps establish boundaries. This intervention empowers the patient to take responsibility for their care and reduces the reliance on manipulation of others.
Choice B is incorrect because negative reinforcement may exacerbate the behavior and lead to further manipulation.
Choice C is incorrect because ignoring inappropriate behavior does not address the underlying issue of ineffective coping and may reinforce the behavior.
Choice D is incorrect because encouraging the patient to discuss feelings of fear and inferiority may be helpful, but it does not directly address the manipulation of others, which is the main concern in this nursing diagnosis.
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Emphasize that the battering pattern usually remains the same in frequency and severity.
- A. By emphasizing that the battering pattern usually remains the same in frequency, it indicates a consistent and recurring nature of the behavior in question.
- B. The battering pattern may change over time.
- C. The battering pattern is unpredictable.
- D. None of the above.
Correct Answer: A
Rationale: The correct answer is A because emphasizing that the battering pattern usually remains the same in frequency highlights the consistent and recurring nature of the behavior. This implies that the pattern is predictable and stable. Choice B is incorrect because it contradicts the idea of consistency in the battering pattern. Choice C is incorrect because it suggests unpredictability, which goes against the notion of the pattern remaining the same. Choice D is incorrect because option A aligns with the concept of the battering pattern being consistent in frequency and severity.
When people successfully adapt to their environment by using logical thought and socially appropriate ways, they are said to be functioning at the adaptive end of the _____ continuum.
- A. Emotional
- B. Self-protective
- C. Neurobiological
- D. Psychobiological
Correct Answer: C
Rationale: The correct answer is C: Neurobiological. This is because neurobiological factors refer to the brain's functioning and how it affects behavior and cognition. When individuals adapt to their environment using logical thought and socially appropriate ways, it indicates a high level of cognitive and behavioral functioning, which is closely tied to neurobiological processes.
A: Emotional is incorrect because emotional factors focus on feelings and affective responses, not necessarily on logical thought and social appropriateness.
B: Self-protective is incorrect as it pertains to behaviors aimed at ensuring one's safety and security, which may not necessarily involve logical thought and social appropriateness.
D: Psychobiological is incorrect as it encompasses the interaction between psychological and biological processes, which may not specifically relate to adaptive functioning in the given context.
A patient diagnosed with schizophrenia reveals to the nurse that voices have warned of danger and adds, 'They're so loud they frighten me. Do you hear them?' The nurse's best initial response would be:
- A. I know these voices are very real to you, but I don't hear them.'
- B. Don't worry. You're safe in the hospital. I won't let anything happen to you.'
- C. Tell me more about the voices. Are they men or women? How many are there?'
- D. What do you do in order to keep yourself occupied so you don't hear the voices?'
Correct Answer: A
Rationale: The correct answer is A because it acknowledges the patient's experience without dismissing or invalidating it. By stating, "I know these voices are very real to you, but I don't hear them," the nurse validates the patient's reality and expresses empathy. This response helps build trust and rapport, which is crucial in establishing a therapeutic relationship.
Choice B is incorrect because it dismisses the patient's concerns and offers false reassurance, which may not be effective in addressing the patient's distress.
Choice C is incorrect as it focuses on gathering more information about the voices without addressing the patient's immediate emotional distress.
Choice D is incorrect because it shifts the focus away from the patient's current experience and onto distractions, which may not be helpful in addressing the patient's distressing symptoms.
An elderly patient brings a bag of medications to the clinic. The nurse finds bottles of medications as well as assorted pills in no containers in the bag. What is the nurse's priority action?
- A. Dispose of all medications that are not in properly labeled bottles.
- B. Confer with a family member about the patient's management of medication.
- C. Engage the patient in education about safe storage and labeling of medication.
- D. Ask the patient to name the purpose and date of expiration of each medication not in a bottle.
Correct Answer: C
Rationale: The correct answer is C because engaging the patient in education about safe storage and labeling of medication is the priority action. This approach promotes patient understanding and empowerment in managing their medications safely. It addresses the immediate concern of the medications being improperly stored and unlabeled. Option A focuses solely on disposal without addressing the root cause. Option B involves a third party and may not address the patient's immediate needs. Option D is important but not as urgent as ensuring safe storage and labeling. Ultimately, educating the patient promotes long-term safety and adherence to medication management.
What is a common consequence of long-term purging in patients with bulimia nervosa?
- A. Improved digestive health and better nutrient absorption.
- B. Increased risk of dehydration and electrolyte imbalances.
- C. Improved self-esteem and body image.
- D. Decreased risk of cardiovascular problems and hypertension.
Correct Answer: B
Rationale: The correct answer is B because long-term purging in patients with bulimia nervosa can lead to increased risk of dehydration and electrolyte imbalances. Purging behaviors such as vomiting or laxative abuse can disrupt the body's fluid and electrolyte balance, potentially causing dehydration and electrolyte imbalances. These imbalances can have serious health consequences, including cardiac arrhythmias, muscle weakness, and kidney damage.
Incorrect choices:
A: Improved digestive health and better nutrient absorption - Purging does not improve digestive health or nutrient absorption; rather, it can lead to nutrient deficiencies.
C: Improved self-esteem and body image - Purging behaviors are harmful and do not lead to improved self-esteem or body image.
D: Decreased risk of cardiovascular problems and hypertension - Purging behaviors can actually increase the risk of cardiovascular problems due to electrolyte imbalances and dehydration.