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Which of the following is an effective communication technique that should be included in the teaching plan for the family members of a woman in whom Alzheimer's disease has been diagnosed recently?
- A. Use simple, familiar words, along with short and simple sentences.
- B. If the client tends to pace a lot, be sure to encourage her to sit during interactions.
- C. If she doesn't understand the communication, change key words.
- D. Use hand gestures when speaking to try to explain what is being said.
Correct Answer: A
Rationale: The correct answer is A: Use simple, familiar words, along with short and simple sentences. This is an effective communication technique for individuals with Alzheimer's disease as it helps in enhancing understanding and reduces confusion. Complex language or sentences may be difficult for the patient to comprehend.
Choice B is incorrect because encouraging the client to sit during interactions does not directly relate to effective communication techniques. Choice C is incorrect as changing key words can lead to further confusion and may not aid in understanding. Choice D is incorrect because using hand gestures may not always effectively convey the message and can potentially cause more confusion for individuals with Alzheimer's disease.
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A woman who is a victim of severe emotional violence tells the nurse that her husband abuses her most often when he is intoxicated, just as his father had beaten him and his mother. The woman is aware of the location of a safe house and has considered leaving home with her two children, but she cites being brought up to believe 'you keep quiet and stay together, no matter what happens.' She states the husband is always apologetic and remorseful after an incident. The nurse responds, 'You cannot live like this; you have to defend yourself and your children.' Which statement most accurately describes the nurse's response?
- A. It is an honest and direct response that will help build trust and rapport.
- B. It suggests that the nurse herself has been a victim of physical abuse.
- C. It is unprofessional, but it will likely help by motivating the patient.
- D. It is a human but unprofessional response and is not helpful.
Correct Answer: D
Rationale: The correct answer is D because the nurse's response is not helpful. Here's a step-by-step rationale:
1. The nurse's response is human because she empathizes with the woman's situation.
2. However, the response is unprofessional as it is too directive and lacks a proper assessment or exploration of the woman's feelings and options.
3. Telling the woman to defend herself may put her at further risk and does not address the underlying issues of abuse and trauma.
4. The response fails to consider the complexities of the woman's situation, such as her cultural beliefs and the cycle of violence she is caught in.
5. Instead, a professional response would involve a more holistic approach, including safety planning, providing resources, and offering support without judgment or pressure.
An elderly client was well until 12 hours ago, when she reported to her family that during the evening she saw strange faces peering in her windows and in the middle of the night awakened to see a man standing at the foot of her bed. She admits to being very frightened. She is presently pacing and somewhat agitated in the examining room. The client's family reports that the client has recently been to the doctor, who made some medication changes, although they are unsure what the changes were. Which nursing intervention should the nurse implement at the time of this client's admission?
- A. Interact with the client on an adult to child level.
- B. Place the client in a safe, nonstimulating environment.
- C. Ask client why she thinks someone would be trying to frighten her.
- D. Explain to the family that the client will be restrained for her own good.
Correct Answer: B
Rationale: The correct answer is B: Place the client in a safe, nonstimulating environment. This is the most appropriate nursing intervention because the client is experiencing hallucinations and agitation, which could be due to the recent medication changes. Placing the client in a safe, calm environment can help reduce stimulation and provide a sense of security. This intervention addresses the client's immediate needs by ensuring her safety and promoting a sense of comfort.
Incorrect answers:
A: Interact with the client on an adult to child level - This is not appropriate as it does not address the client's current state of distress and could potentially worsen the situation.
C: Ask client why she thinks someone would be trying to frighten her - This is not the priority at this time, as the client is experiencing hallucinations and agitation that need to be managed first.
D: Explain to the family that the client will be restrained for her own good - Restraints should only be used as a last resort and should not be considered
What is the most important goal for a nurse when providing care for a patient with bulimia nervosa?
- A. To promote weight loss through strict dietary control.
- B. To help the patient eliminate purging behaviors and develop healthy eating habits.
- C. To encourage excessive exercise to balance caloric intake.
- D. To focus solely on addressing body image issues.
Correct Answer: B
Rationale: The correct answer is B: To help the patient eliminate purging behaviors and develop healthy eating habits. This goal is important because it addresses the core issues of bulimia nervosa, which are unhealthy purging behaviors and distorted eating patterns. By helping the patient stop purging and establish healthy eating habits, the nurse can promote long-term recovery and overall well-being.
Choice A is incorrect because promoting weight loss through strict dietary control can exacerbate the patient's unhealthy relationship with food and body image. Choice C is incorrect as encouraging excessive exercise can contribute to a cycle of compulsive behaviors and worsen the patient's physical and mental health. Choice D is incorrect because focusing solely on body image issues neglects the underlying psychological factors contributing to bulimia nervosa.
A client is admitted to a day hospital following an episode in which he purchased a gun to use while standing guard over his property to prevent a neighbor from erecting a boundary fence. His wife describes him as distrustful of the motives of others and often interpreting others' motives as threats. She mentions that one time he accused her of having an affair with a neighbor with whom she chatted occasionally. The care plan will list the priority outcome as 'Client will:
- A. admit his action was excessive based on the circumstance.
- B. write the neighbor a letter of apology.
- C. demonstrate trust in the nurse.
- D. identify positive role models.'
Correct Answer: C
Rationale: The correct answer is C: demonstrate trust in the nurse. This is the priority outcome because the client's lack of trust and tendency to perceive threats need to be addressed first. By demonstrating trust in the nurse, the client can begin to develop a therapeutic relationship, which is essential for addressing his distrustful behavior and interpreting threats. This outcome focuses on building rapport and establishing a foundation for therapeutic interventions.
Choice A is incorrect because admitting his action was excessive may not address the underlying issues of distrust and misinterpretation of motives. Choice B is incorrect as it does not address the client's core issues and may not be appropriate in this context. Choice D is also incorrect as identifying positive role models is not a priority when the client's trust and perception issues need immediate attention.
If you met an individual who appeared to be very charming at first, but later you discovered that he or she manipulated people, caused others hurt without a second thought, and could not be depended upon, you might suspect him of being
- A. dependent
- B. narcissistic
- C. paranoid
- D. antisocial
Correct Answer: D
Rationale: Antisocial personality disorder features charm, manipulation, and lack of remorse, fitting this description perfectly.