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Which nursing strategy leads patients to respond more positivity 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 rapport and trust. By acknowledging the patient's feelings, it can help them feel heard and understood, leading to a more positive response to limit setting.
Choice A is incorrect because confrontation can lead to defensiveness and resistance. Choice B focuses on exploring underlying dynamics without addressing the immediate behavior. Choice D may come off as judgmental and punitive, potentially escalating the situation.
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A 17-year-old client is admitted to the ED after being alternately hyperalert and difficult to arouse. His symptoms all started within the last few hours, during which time he became agitated and restless, and his memory was impaired, especially for recent events. The client displayed some delusions and misinterpretations of his surroundings. The nurse knows she needs to assess the client further for:
- A. Drug use.
- B. Infection.
- C. Metabolic disorder.
- D. None of the above.
Correct Answer: A
Rationale: The correct answer is A: Drug use. Given the client's sudden onset of symptoms, including altered mental status, agitation, memory impairment, delusions, and misinterpretations of surroundings, drug use is the most likely cause. Step 1: Consider the timeline - symptoms started within a few hours. Step 2: Review the symptoms - agitation, memory impairment, delusions, altered mental status. Step 3: Think of common causes for acute onset of these symptoms - drug use can lead to these manifestations. Step 4: Rule out other potential causes - infection and metabolic disorders typically present with different symptomatology and are less likely in this acute scenario. Step 5: Therefore, the nurse should prioritize assessing the client for drug use to provide appropriate interventions.
The early stage of Alzheimer's disease is characterized by:
- A. Loss of recent memory
- B. Loss of remote memory
- C. Withdrawal from family
- D. Apraxia
Correct Answer: A
Rationale: The correct answer is A: Loss of recent memory. In the early stage of Alzheimer's disease, individuals typically experience difficulty remembering recent events, conversations, or information. This is due to the initial impact of the disease on the hippocampus and other brain regions responsible for forming new memories. Choices B, C, and D are incorrect because loss of remote memory (choice B) usually occurs in later stages, withdrawal from family (choice C) can be a result of various factors beyond memory loss, and apraxia (choice D) refers to the inability to perform coordinated movements and is not a primary symptom of early-stage Alzheimer's.
A patient with borderline personality disorder has been making steady progress but one day gets a phone call from her boyfriend, who breaks off their relationship. Although she has not self-injured in over 2 months, she makes repeated lacerations on her forearm. Which statement about this and most maladaptive behaviors seen in personality disorders is most accurate?
- A. People with personality disorders rarely achieve lasting improvement.
- B. However dysfunctional, most behavior is the person's best effort to cope.
- C. People with personality disorders are at the mercy of others' actions.
- D. What appears to be improvement can be manipulation instead.
Correct Answer: B
Rationale: The correct answer is B: However dysfunctional, most behavior is the person's best effort to cope. In this scenario, the patient's self-injury following the breakup is a maladaptive coping mechanism to deal with emotional distress. Individuals with personality disorders often engage in maladaptive behaviors as a way to cope with overwhelming emotions or stress. This behavior may not be effective or healthy, but it is their attempt to manage their internal struggles.
A: People with personality disorders rarely achieve lasting improvement - This statement is incorrect as individuals with personality disorders can make progress with therapy and support.
C: People with personality disorders are at the mercy of others' actions - This statement is incorrect as individuals with personality disorders have agency over their behaviors, even if they struggle with emotional regulation.
D: What appears to be improvement can be manipulation instead - This statement is incorrect as improvement in behavior should not be automatically attributed to manipulation; it could genuinely reflect progress in coping skills.
The psychiatric-mental health nurse, who is teaching a patient's parents how to use positive reinforcement techniques with the patient, recommends:
- A. agreeing with the child's statements, whether negative or positive, and simply restating the child's statements without other comment
- B. controlling the child's behavior, so there is no chance of negative behavior
- C. removing adverse consequences to produce positive results
- D. rewarding positive behaviors to promote their recurrence
Correct Answer: D
Rationale: Positive reinforcement rewards desired behaviors, increasing their frequency, a core behavioral strategy.
The first step in the treatment of incest is to:
- A. believe the child who reports the activity
- B. notify the proper authorities
- C. objectively confront the accused family member
- D. remove the child from the home
Correct Answer: A
Rationale: Believing the child establishes trust and validates their experience, forming the foundation for further protective and therapeutic actions.