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Which nursing diagnosis is a priority for both a patient with depression and one with acute mania?
- A. Deficient diversional activity
- B. Disturbed sleep pattern
- C. Fluid volume excess
- D. Defensive coping
Correct Answer: B
Rationale: The correct answer is B: Disturbed sleep pattern. Both depression and acute mania can disrupt sleep, leading to negative impacts on overall health. Sleep disturbances can exacerbate symptoms of both conditions and hinder recovery. Addressing sleep patterns is crucial in managing symptoms and improving outcomes for patients with depression and acute mania.
A: Deficient diversional activity is more relevant to depression than acute mania, as patients with mania often engage in excessive activities.
C: Fluid volume excess is not typically associated with depression or acute mania.
D: Defensive coping may be relevant to both conditions but is not a priority compared to addressing sleep patterns for patient safety and symptom management.
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What should the nurse focus on when planning care for a patient with anorexia nervosa?
- A. Encourage the patient to restrict food intake and control weight.
- B. Provide a structured meal plan and monitor nutritional intake.
- C. Allow the patient to eat freely without any food restrictions.
- D. Encourage daily exercise to help manage weight.
Correct Answer: B
Rationale: The correct answer is B because providing a structured meal plan and monitoring nutritional intake is crucial in the care of a patient with anorexia nervosa to ensure they receive adequate nutrition. By following a structured plan, the patient can gradually restore a healthy relationship with food and gain weight safely. Encouraging the patient to eat freely (choice C) can lead to further disordered eating behaviors. Encouraging food restriction and weight control (choice A) can worsen the patient's condition. Encouraging daily exercise (choice D) may exacerbate the patient's excessive focus on weight and body image. In summary, choice B is the best option as it focuses on promoting healthy eating habits and addressing the nutritional needs of the patient with anorexia nervosa.
A student nurse visiting a senior center says, 'It's depressing to see these old people. They are weak and frail. I doubt any of them can engage in a discussion.' The student is expressing
- A. reality
- B. ageism
- C. empathy
- D. vulnerability
Correct Answer: B
Rationale: The correct answer is B: ageism. The student nurse's statement demonstrates prejudice and discrimination based on age. Ageism is the negative stereotypes, prejudice, and discrimination against individuals or groups based on their age. In this case, the student is making assumptions about the abilities and worth of older individuals solely based on their age. The statement does not reflect reality, as not all older people are weak or unable to engage in meaningful discussions. The other choices are incorrect as the statement is not reflective of reality (A), empathy (C), or vulnerability (D).
A child, age 9, is being evaluated in the Emergency Department at the hospital. Her mother is with her and describes her as withdrawn and quiet. The nurse practitioner suspects child abuse. Which of these findings indicates that physical abuse may be a chronic problem for the child?
- A. The presence of the mother and her description of the child as withdrawn and quiet.
- B. The child's refusal to speak to the nurse.
- C. The child's physical appearance.
- D. None of the above.
Correct Answer: A
Rationale: The correct answer is A because the mother's description of the child as withdrawn and quiet can indicate chronic physical abuse. This is because a child who is consistently withdrawn and quiet may be exhibiting signs of trauma from ongoing abuse. The mother's presence is also important as it provides insight into the child's home environment.
Explanation for why the other choices are incorrect:
B: The child's refusal to speak to the nurse may indicate shyness or fear, but it does not specifically point to chronic physical abuse.
C: The child's physical appearance alone does not provide enough information to determine if physical abuse is chronic.
In summary, choice A is the correct answer as it directly relates to potential signs of chronic physical abuse, while choices B and C do not provide sufficient evidence to support this conclusion.
A newly admitted patient with schizophrenia approaches the unit nurse and says, 'The voices are bothering me. They are yelling and telling me stuff. They are really bad.' Which response by the nurse would be most appropriate?
- A. Do you hear these voices very often?'
- B. Do you have a plan for getting away from the voices?'
- C. I'll stay with you. Tell me what you are hearing.'
- D. Try to ignore them and play cards with the others.'
Correct Answer: C
Rationale: The correct answer is C because it demonstrates active listening and empathy, which can help establish trust and rapport with the patient. By saying, "I'll stay with you. Tell me what you are hearing," the nurse acknowledges the patient's distress and offers support. This response can help the patient feel heard and understood, which is crucial in managing symptoms of schizophrenia.
Choice A is incorrect as it focuses more on the frequency rather than addressing the immediate distress. Choice B is incorrect as it assumes the patient has a plan to escape the voices, which may not be the case and can escalate the situation. Choice D is incorrect as it dismisses the patient's experience and suggests distraction rather than addressing the underlying issue.
A nursing colleague says, 'This patient was admitted claiming to have been raped by her boyfriend, but just look at the sexy clothes she's wearing.' Which response reflects an understanding of the most likely source of the colleague's comment?
- A. Have you ever cared for other sexual assault victims?'
- B. Your sister was raped when she was in college, wasn't she?'
- C. You have three unmarried brothers about the patient's age, don't you?'
- D. Do you think that wearing sexy clothes caused her to be sexually assaulted?'
Correct Answer: D
Rationale: The correct answer is D because it addresses the underlying misconception that a person's clothing choices can justify or provoke sexual assault. By asking if the colleague believes the victim's clothing caused the assault, it challenges victim-blaming and highlights the importance of understanding consent and boundaries.
Option A does not directly address the colleague's potentially victim-blaming statement. Option B brings up the colleague's personal experience, which is irrelevant and may not effectively challenge the problematic comment. Option C makes assumptions about the colleague's personal life, which is not relevant to the situation at hand.