Nokea
Which nursing progress note would most suggest that the treatment plan of a severely depressed and withdrawn patient has been effective?
- A. Slept 6 hours straight, sang with activity group, eager to see grandchild.
- B. Slept 8 hours, attended craft group, ate half of lunch, denies suicidal ideation.
- C. Slept 10 hours, personal hygiene adequate with assistance, lost one pound.
- D. Slept 7 hours on and off, reports "food has no taste", no self-harm noted.
Correct Answer: A
Rationale: The correct answer is A because it indicates positive changes in mood, engagement, and social interaction, which are key indicators of effective treatment for severe depression. Sleeping 6 hours straight shows improved sleep patterns, singing with the activity group reflects increased participation and enjoyment, and being eager to see the grandchild demonstrates a renewed sense of joy and connection.
Choice B is incorrect because although the patient denies suicidal ideation, the level of activity and engagement is not as high as in choice A. Choice C is incorrect as the focus is on physical aspects rather than emotional well-being and social interaction. Choice D is incorrect because the patient still shows signs of depression such as lack of appetite and loss of interest in activities.
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A client has been diagnosed with a dementia secondary to cerebral disease. The family members note the client 'has not been as sharp as he once was' and that he has developed urinary incontinence and a gait disturbance. They attributed the first symptom to normal aging but were alarmed by the latter two symptoms. Based on this history, which of the following should come to mind?
- A. Normal pressure hydrocephalus
- B. Vitamin B12 deficiency
- C. Hepatic disease
- D. Tuberculosis
Correct Answer: A
Rationale: Step 1: The client presents with urinary incontinence and a gait disturbance, suggestive of normal pressure hydrocephalus (NPH) due to cerebral disease.
Step 2: NPH is characterized by the triad of cognitive decline, gait disturbances, and urinary incontinence.
Step 3: Symptoms of NPH can mimic normal aging but are distinct from other conditions.
Step 4: Vitamin B12 deficiency (B) primarily presents with anemia and neurological symptoms, not the triad seen in NPH.
Step 5: Hepatic disease (C) typically presents with symptoms related to liver dysfunction, not the triad of NPH.
Step 6: Tuberculosis (D) manifests with respiratory symptoms and constitutional symptoms, not the cognitive decline and gait issues seen in NPH.
A nurse assessing an elderly patient for depression and suicide potential should include questions about mood as well as: (Select one tha does not apply)
- A. anhedonia.
- B. increased appetite.
- C. sleep pattern changes.
- D. increased concerns with bodily functions.
Correct Answer: B
Rationale: The correct responses (A, C, E) relate to symptoms often noted in elderly patients with depression: anhedonia (loss of pleasure), sleep changes, and somatic concerns. Increased appetite (B) is less typical than anorexia, and grandiosity (D) relates to bipolar disorder, not depression.
The nurse reports to the interdisciplinary team that an antisocial patient lies to other patients, verbally abuses a patient with Alzheimer's disease, flatters his primary nurse, and is detached and superficial during counseling sessions. Which behavior should be the priority focus of limit setting?
- A. Lying to other patients
- B. Flattering the nursing staff
- C. Verbally abusing other patients
- D. Superficiality during counseling
Correct Answer: C
Rationale: The priority focus of limit setting should be on verbally abusing other patients (Choice C) because it directly harms others and creates a hostile environment. This behavior is not only detrimental to the well-being of other patients but also disrupts the therapeutic milieu. Limiting this behavior is crucial to ensure the safety and emotional health of all patients in the care setting. Lying to other patients (Choice A), flattering the nursing staff (Choice B), and being superficial during counseling sessions (Choice D) are concerning behaviors as well, but they do not pose an immediate risk to the safety and well-being of others in the same way that verbal abuse does. It is important to address all inappropriate behaviors, but the priority should be given to the behavior that has the most significant negative impact on the therapeutic environment.
The family of a client mentions to the nurse, 'The family therapist talked to us about enmeshment. We're not sure we understood what it meant.' The nurse should base a response on knowledge that an enmeshed family is a unit in which:
- A. individuality is encouraged.
- B. boundaries are poorly defined.
- C. conflict is effectively resolved.
- D. social acceptance is deemed unimportant.
Correct Answer: B
Rationale: The correct answer is B: boundaries are poorly defined. In an enmeshed family, boundaries between family members are blurred, leading to a lack of individual autonomy and independence. Enmeshment can result in difficulties in establishing personal identities and healthy relationships. Choices A, C, and D are incorrect because individuality is not encouraged, conflict is not effectively resolved, and social acceptance is not necessarily deemed unimportant in an enmeshed family dynamic.
What role does play have in mental development?
- A. Minimal
- B. Develops social skills only
- C. Enhances imagination and reasoning
- D. Physical benefits only
Correct Answer: C
Rationale: Play enhances imagination and reasoning (C), fostering cognitive growth. It's not minimal (A), not just social (B), or only physical (D), per child development research.