Nokea
Which nursing strategy leads patients to respond more positively to limit setting?
- A. Confront the patient with the inappropriateness of the behavior.
- B. Explore with the patient the underlying dynamics of the behavior.
- C. Reflect back to the patient an understanding of the patient's distress.
- D. State clear disapproval of the behavior, and support its consequences.
Correct Answer: C
Rationale: The correct answer is C because reflecting back to the patient an understanding of their distress shows empathy and validation, which can help build a therapeutic relationship and lead to a more positive response to limit setting. This approach acknowledges the patient's feelings without judgment, fostering trust and cooperation.
Choice A is incorrect as confrontation may lead to defensiveness and resistance. Choice B is incorrect as exploring underlying dynamics may not address the immediate need for setting limits. Choice D is incorrect as clear disapproval and consequences may create a negative, punitive atmosphere rather than promoting understanding and collaboration.
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A patient, aged 77 years, has Alzheimer's disease. She goes to day care during the week and is otherwise cared for by her daughter and grandchildren. The nurse at the day care center noticed multiple bruises on the patient's palms, elbows, and buttocks. 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 she cannot recognize me and accuses me of trying to poison her. I can't concentrate at work, and it's wrecking the family. Sometimes I just cannot bear it."Â Which nursing diagnosis would be most important to address for this family?
- A. Knowledge deficit pertaining to dementia
- B. Grieving related to mother's deterioration
- C. Risk for injury related to cognitive impairment
- D. Caregiver role strain related to increased care needs
Correct Answer: D
Rationale: The correct nursing diagnosis to address in this scenario is D: Caregiver role strain related to increased care needs. This is the most important as it focuses on the daughter's challenges and emotional burden due to her mother's condition. The daughter's statements reveal feelings of overwhelm, guilt, and exhaustion, which are key indicators of caregiver role strain. By addressing this nursing diagnosis, the healthcare team can provide support and resources to help the daughter cope with the demands of caring for her mother.
Choice A (Knowledge deficit pertaining to dementia) is not the most important in this situation as the daughter's issue is not lack of knowledge but rather emotional stress. Choice B (Grieving related to mother's deterioration) is not the priority as addressing the daughter's emotional strain is more urgent than addressing grief. Choice C (Risk for injury related to cognitive impairment) is also important but not as immediate as addressing the caregiver's emotional well-being.
According to the map showing deaths resulting from poor air quality worldwide, which regions of the world have the poorest air quality?
- A. Brazil
- B. China
- C. Canada
- D. Australia
Correct Answer: B
Rationale: China has some of the poorest air quality globally due to industrial pollution and urbanization, as shown in air quality death maps.
A nurse plans an educational program for staff of a home health agency specializing in care of the elderly. Which topic is the highest priority to include?
- A. Pain assessment techniques for older adults
- B. Psychosocial stimulation for those who live alone
- C. Preparation of psychiatric advance directives in the elderly
- D. Ways to manage disinhibition in elderly persons with dementia
Correct Answer: A
Rationale: The topic of greatest immediacy is the assessment of pain in older adults. Unmanaged pain can precipitate other problems, such as substance abuse and depression. Elderly patients are less likely to be accurately diagnosed and adequately treated for pain. The distracters are unrelated or of lesser importance.
When making a distinction as to whether an elderly patient has confusion related to delirium or another problem, what information would be of particular value?
- A. Evidence of spasticity or flaccidity
- B. The patient's level of motor activity
- C. Medications the patient has recently taken
- D. Level of preoccupation with somatic symptoms
Correct Answer: C
Rationale: The correct answer is C: Medications the patient has recently taken. This information is crucial because certain medications can cause delirium in elderly patients. By reviewing the patient's recent medications, healthcare providers can identify potential drug-induced delirium and adjust treatment accordingly. Spasticity or flaccidity (choice A) is more indicative of neurologic conditions, not delirium. The patient's level of motor activity (choice B) may provide some insight but is not as specific to delirium as medication history. The level of preoccupation with somatic symptoms (choice D) is more relevant to other psychiatric conditions and does not directly help in distinguishing delirium.
The first step in the creation of a therapeutic alliance between a nurse and a patient with a maladaptive response to eating regulation is:
- A. formulation of a nurse-patient contract.
- B. resolution of conflicts with family members.
- C. nurse and patient will agree on perception of patient's body.
- D. the means of stabilizing the patient's nutritional status will be specified.
Correct Answer: A
Rationale: The correct answer is A: formulation of a nurse-patient contract. This is because establishing a clear agreement outlining the roles, responsibilities, and boundaries between the nurse and patient is crucial in building trust and collaboration. It sets the foundation for a therapeutic alliance by promoting mutual understanding and shared goals.
Summary:
B: Resolving conflicts with family members may be important for overall well-being but is not the first step in creating a therapeutic alliance.
C: Agreeing on the patient's body perception is important but does not address the fundamental establishment of trust through a contract.
D: Specifying means of stabilizing nutritional status is essential but comes after the initial agreement on roles and responsibilities.