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Which intervention would be the best initial approach for a nurse to take when a young adult patient is verbally abusive?
- A. Ask the patient to define 'verbally abusive language.'
- B. Provide the patient with examples of assertive communication.
- C. Identify the patient's verbal abuse in order to set standards for future dialogue.
- D. Remove privileges from the patient until communications show less aggression.
Correct Answer: C
Rationale: The correct initial approach is to identify the patient's verbal abuse to set standards for future dialogue. This approach addresses the behavior directly, establishes boundaries, and communicates expectations for respectful communication. Asking the patient to define 'verbally abusive language' (choice A) may not effectively address the current behavior. Providing examples of assertive communication (choice B) may not directly address the abusive behavior. Removing privileges (choice D) may escalate the situation and is not a constructive communication strategy. By identifying the patient's verbal abuse, the nurse can address the behavior effectively and work towards a respectful and therapeutic relationship.
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A patient remanded by the court after his wife had him jailed for battery told the judge how sorry he was and suggested he needed psychiatric help. His history reveals acting-out behaviors as an adolescent and several adult arrests. The nurse interviews him about his relationship with his wife. Which statement by the patient is most consistent with a diagnosis of antisocial personality disorder?
- A. I've done some stupid things in my life, but I've learned a lesson.'
- B. I'm feeling terrible about the way my behavior has hurt my family.'
- C. I have a quick temper, but I can usually keep it under control.'
- D. I hit her because she nags at me. She deserves it when I beat her up.'
Correct Answer: D
Rationale: The correct answer is D because it demonstrates a lack of remorse, empathy, and justification for violent behavior, which are key characteristics of antisocial personality disorder. The statement indicates a pattern of blaming others for his actions and a sense of entitlement to use violence as a means of control.
Choice A is incorrect because it shows acknowledgment of past mistakes and a willingness to learn from them, which is not typical of individuals with antisocial personality disorder. Choice B is incorrect as it reflects genuine regret and concern for the impact of his actions, which is inconsistent with the disorder. Choice C is incorrect because it implies an ability to control his temper, whereas individuals with antisocial personality disorder often struggle with impulsivity and aggression.
A patient with severe dementia can no longer recognize her only daughter and becomes anxious and agitated when the daughter attempts to reorient her. An alternative the nurse could suggest to the daughter is to:
- A. Wear a large name tag.
- B. Visit her mother less often.
- C. Talk about experiences they've shared.
- D. None of the above.
Correct Answer: C
Rationale: The correct answer is C: Talk about experiences they've shared. This option is the most appropriate because reminiscing about past shared experiences can help trigger memories and emotions in the patient with dementia, potentially reducing anxiety and agitation. It can provide comfort and a sense of familiarity to the patient. Wearing a large name tag (option A) may not address the core issue of memory loss. Visiting less often (option B) could lead to further feelings of isolation and confusion for the patient. Option D, None of the above, is incorrect as option C provides a constructive and person-centered approach to improving the interaction between the patient and her daughter.
A victim of spousal abuse comes to the emergency department for treatment of a broken arm. She appears hypervigilant and anxious and admits to sleep disturbance when the nurse questions the dark circles under her eyes. She reluctantly tells the nurse the abuse usually occurs when the husband has been drinking, although she concedes he is always jealous and controlling. She is a stay-at-home mother of two preschool children. The family has lived in this town for 1 month. The patient states she has fleetingly considered suicide but must stay alive to care for her children and work her way out of the abusive relationship. She denies any further suicidal thoughts. The nurse should document in the medical record that: (Select all that apply.)
- A. Signs of high anxiety and chronic stress are present.
- B. The patient relies on the perpetrator for basic needs.
- C. The patient has a history of suicidal ideation.
- D. None of the above.
Correct Answer: A
Rationale: The correct answer is A: Signs of high anxiety and chronic stress are present.
Rationale:
1. The patient displaying hypervigilance, anxiety, sleep disturbances, and dark circles under her eyes are indicators of high anxiety and chronic stress, common in victims of abuse.
2. Mentioning abuse occurring when the husband drinks, his jealousy, and control further support the presence of chronic stress and anxiety.
3. The patient's fleeting suicidal thoughts are a response to the abusive situation, not indicative of a history of suicidal ideation.
Summary:
B: The patient relying on the perpetrator for basic needs is not supported by the information provided.
C: There is no indication of a history of suicidal ideation, as the patient's thoughts are tied to her children and escaping the abusive relationship.
A nurse and social worker co-lead a reminiscence group for eight young-old adults. Which activity is most appropriate to include in the group?
- A. Mild aerobic exercise
- B. Singing a song from World War II
- C. Discussing national leadership during the Vietnam War
- D. Identifying the most troubling story in today's newspaper
Correct Answer: C
Rationale: The correct answer is C. Discussing national leadership during the Vietnam War is most appropriate as it aligns with the reminiscence therapy goal of recalling past experiences to promote social interaction and cognitive stimulation. It is relevant to the age group of young-old adults who may have lived through that era, sparking meaningful discussions. Choice A does not directly relate to reminiscence therapy. Choice B may not resonate with all group members. Choice D focuses on negative news, which is not conducive to the therapeutic purpose.
Which of the following is a priority nursing intervention for a patient with anorexia nervosa during the refeeding process?
- A. Encourage the patient to engage in physical activity to stimulate appetite.
- B. Monitor vital signs and electrolyte levels to avoid refeeding syndrome.
- C. Offer high-calorie snacks to speed up weight gain.
- D. Focus on the patient's body image concerns before addressing nutrition.
Correct Answer: B
Rationale: The correct answer is B because monitoring vital signs and electrolyte levels is crucial during the refeeding process to prevent refeeding syndrome, a potentially life-threatening complication. This intervention ensures early detection of any electrolyte imbalances or cardiac complications that may arise as the body readjusts to increased food intake. Encouraging physical activity (A) can be harmful due to the patient's compromised state. Offering high-calorie snacks (C) may lead to rapid weight gain and increase the risk of refeeding syndrome. Focusing on body image concerns (D) is important but should not take precedence over addressing the patient's immediate medical needs.