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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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What is the most appropriate goal for a nurse caring for a patient with anorexia nervosa?
- A. The patient will gain weight rapidly to achieve a normal weight.
- B. The patient will stabilize their weight and maintain adequate nutrition.
- C. The patient will achieve full recovery without needing additional support.
- D. The patient will accept their body image as normal and healthy.
Correct Answer: B
Rationale: The most appropriate goal for a nurse caring for a patient with anorexia nervosa is for the patient to stabilize their weight and maintain adequate nutrition (Choice B). This goal is crucial because rapid weight gain can have negative physical and psychological consequences for the patient. Stabilizing weight helps prevent complications like refeeding syndrome and supports the patient's overall health. It also addresses the immediate nutritional needs of the patient. Choices A, C, and D are incorrect because rapid weight gain can be harmful, full recovery often requires ongoing support, and body image acceptance may not be the most pressing concern for someone with anorexia nervosa.
A patient, aged 82 years, has Alzheimer's disease. She lives with her daughter's family and goes to a day care facility on weekdays. The nurse at the day care center noticed the patient was unkempt and had multiple bruises. When the daughter arrived to pick her up, the nurse discussed her observations. The daughter became defensive and said that her mother was very difficult to manage. She stated, "My mother is not my mother anymore. She is confused, and she wanders all night. We have to watch her constantly. Last night I fell asleep, and she fell down the stairs. Sometimes I just cannot bear to care for her."Â Which nursing diagnosis would be most important to address for this patient?
- A. Risk for injury related to impaired cognition, judgment, and coordination and lack of caregiver supervision
- B. Nonadherence related to confusion and disorientation, as evidenced by lack of cooperation
- C. Anxiety related to increasing disorientation, as evidenced by the patient wandering at night
- D. Impaired verbal communication related to brain impairment, as evidenced by the patient's confusion
Correct Answer: A
Rationale: The correct answer is A: Risk for injury related to impaired cognition, judgment, and coordination and lack of caregiver supervision. The rationale is that the patient's Alzheimer's disease has led to impaired cognitive function, making her at risk for injury due to wandering and falls. The daughter's lack of supervision and inability to manage the patient's needs further exacerbate this risk. Choices B, C, and D are incorrect because they do not directly address the immediate safety concern of the patient being at risk for injury. Nonadherence, anxiety, and impaired communication are important issues but do not take precedence over the patient's safety in this context.
A nurse is caring for a patient with bulimia nervosa who has not eaten for 24 hours. The nurse should first:
- A. Encourage the patient to eat a full meal immediately.
- B. Assess the patient's vital signs and hydration status.
- C. Provide the patient with a menu to select food for the next meal.
- D. Contact the physician for a medication prescription.
Correct Answer: B
Rationale: The correct answer is B because assessing vital signs and hydration status is crucial in identifying potential complications from prolonged fasting in a patient with bulimia nervosa. This step helps determine the patient's immediate needs for intervention and guides further care planning. Encouraging the patient to eat a full meal immediately (Choice A) may lead to refeeding syndrome due to electrolyte imbalances. Providing a menu for the next meal (Choice C) is not the priority when the patient has not eaten for 24 hours. Contacting the physician for a medication prescription (Choice D) is not necessary at this point without first assessing the patient's current physical status.
The nurse manager of a mental health center wants to improve medication adherence among the seriously mentally ill persons treated there. Which interventions are likely to help achieve this goal? Select one tha does not apply
- A. Maintain stable and consistent staff
- B. Increase the length of medication education groups
- C. Stress that without treatment, illnesses will worsen
- D. Prescribe drugs in smaller but more frequent dosages
Correct Answer: A
Rationale: Trust in ones providers is a key factor in treatment adherence, and mentally ill persons can sometimes take a very long time to develop such trust; therefore, interventions which stabilize staffing allow patients to have more time with staff to develop these bonds. Ready access to prescribers allows medicine-related concerns to be addressed quickly, reducing obstacles to adherence such as side effects or ineffective dosages. Medication costs can be obstacles to adherence as well. Many SMI patients have anosognosia and do not adhere to treatment because they believe they are not ill, so telling them nonadherence will worsen an illness they do not believe they have is unlikely to be helpful. Increasing medication education is helpful only when the cause of nonadherence is a knowledge deficit. Other issues that reduce adherence, particularly anosognosia and side effects, are seldom helped by longer medication education. Requiring medication adherence to participate in other programs is coercive and unethical. Smaller, more frequent doses do not reduce side effects and make the regimen more difficult for the patient to remember.
Which of the following procedures can be used to identify Down Syndrome pre-natally?
- A. Amniocentesis
- B. Amnioprolaxis
- C. Amniophalaxi
- D. Amniocalesis
Correct Answer: A
Rationale: Amniocentesis: A procedure extracting and analyzing amniotic fluid to identify Down Syndrome pre-natally in high-risk parents.