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Which of these nursing interventions would be most effective when using an empowerment model of intervention with an individual who has been abused?
- A. You have left your spouse many times only to return. Please tell me how you view this last time as being different from all the times you left before.'
- B. Last time we talked, you thought your children would miss their father, but you now think they seem happier and almost relieved by your separation.'
- C. So you're having doubts and want to return to your husband even though you know that he broke your arm and caused your miscarriage?'
- D. I support you returning to your spouse until you finally decide that 'enough is enough.''
Correct Answer: B
Rationale: The correct answer is B because it acknowledges the individual's evolving perspective and empowers them to recognize positive changes post-separation. This approach helps the individual build confidence in their decision-making process and fosters self-awareness.
Choice A focuses on past actions without addressing the current situation, Choice C uses a confrontational tone that may cause the individual to feel judged or defensive, and Choice D suggests a passive acceptance of returning to an abusive situation without promoting autonomy or self-efficacy.
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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 disoriented and confused. His behavior was agitated and restless, and his memory was impaired, especially for recent events. The client displayed some delusions and misinterpretations of his surroundings. The nurse's first action should be to:
- A. Take the client's vital signs
- B. Restrain the client to prevent injury
- C. Obtain a pm order for a psychotropic medication
- D. Ask the client for information about his medications
Correct Answer: A
Rationale: The correct answer is A: Take the client's vital signs. The first step in assessing any client in the emergency department is to ensure their physiological stability. Vital signs provide essential information about the client's current physical condition, such as heart rate, blood pressure, respiratory rate, and temperature. In this case, the client's alternating states of hyperalertness and difficulty in arousal, disorientation, confusion, agitation, memory impairment, delusions, and misinterpretations of surroundings indicate a potential medical emergency. Therefore, taking the client's vital signs is crucial to determine if there are any immediate life-threatening conditions that need to be addressed promptly.
Summary of other choices:
B: Restrain the client to prevent injury - Restraint should only be used as a last resort for safety concerns and after assessing the client's physical condition.
C: Obtain a PRN order for a psychotropic medication - Administering psychotropic medication should not be the first action without assessing the client's physical condition and
A new nurse asks, 'My elderly patient's CT scan of the head shows many Lewy bodies are present. What should I do about assessing for pain?' Select the best response from the nurse manager.
- A. Ask the patient's family if they think the patient is experiencing pain.
- B. Use a visual analog scale to help the patient determine the presence and severity of pain.
- C. There are special scales for assessing patients with dementia. Let's review how to use them.
- D. The perception of pain is diminished by this type of dementia. Focus your assessment on the patient's mental status.
Correct Answer: C
Rationale: The correct answer is C because patients with Lewy body dementia may have difficulty expressing pain. Special pain assessment scales designed for patients with dementia can help in accurately assessing pain levels. These scales take into account nonverbal cues and behavioral changes that may indicate pain. By using these specialized tools, the nurse can ensure a more comprehensive assessment of the patient's pain experience.
Choice A is incorrect because relying solely on family members' perceptions may not accurately reflect the patient's actual pain experience.
Choice B is not the best option because a visual analog scale may not be suitable for patients with dementia who may have cognitive impairments affecting their ability to use such tools effectively.
Choice D is incorrect as it assumes that pain perception is diminished in Lewy body dementia without considering that patients may still experience pain but have difficulty communicating it. Focusing solely on mental status may overlook important pain indicators.
A history reveals that a patient virtually stopped eating 5 months ago and lost 25% of body weight. The nurse says, "Describe what you think about your present weight and how you look." Which response would be most consistent with anorexia nervosa?
- A. I'm fat and ugly.
- B. What I think about myself is my business.
- C. I'm grossly underweight, but I cover it well.
- D. I'm a few pounds overweight, but I can live with it.
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. The patient's history of significant weight loss and refusal to eat align with symptoms of anorexia nervosa.
2. Choice A reflects negative body image common in anorexia nervosa, as patients often perceive themselves as overweight and unattractive.
3. Choices B, C, and D do not acknowledge the patient's actual physical condition or the psychological aspect of anorexia nervosa.
4. Choice B avoids the question and lacks insight into the patient's distorted body image.
5. Choice C acknowledges being underweight but does not address the negative self-perception associated with anorexia nervosa.
6. Choice D acknowledges being overweight, which contradicts the patient's actual weight loss history and is inconsistent with anorexia nervosa's symptoms.
A victim of a violent rape was treated in the emergency department. As discharge preparation begins, the victim says softly, "I will never be the same again. I can't face my friends. There is no reason to go on."Â Select the nurse's most appropriate response.
- A. Are you thinking of harming yourself?
- B. It will take time, but you will feel the same.
- C. Your friends will understand when you explain it was not your fault.
- D. You will be able to find meaning in this experience as time goes on.
Correct Answer: A
Rationale: The correct answer is A: "Are you thinking of harming yourself?" This response is the most appropriate because the victim is expressing hopelessness and suicidal ideation, which indicates a need for immediate intervention and assessment for safety. By asking directly about self-harm, the nurse can assess the severity of the situation and take appropriate actions to ensure the victim's safety.
Summary of other choices:
B: This response minimizes the victim's feelings and does not address the seriousness of the situation.
C: This response ignores the victim's emotional distress and does not address the potential for self-harm.
D: This response dismisses the victim's current feelings and does not provide immediate support for the expressed hopelessness.
A patient with many positive symptoms of schizophrenia, whose behavior is disorganized and who is highly anxious, tells the nurse in the psychiatric emergency department, 'You have got to help me. I do not know what is going on. I think someone is trying to wipe me out. I have to get a gun.' The patient, a college student, lives alone and has no family or support system in the immediate area. He has not left his room in 2 weeks, has not eaten in several days, and is unkempt. Of the available treatment settings, the nurse should recommend:
- A. admission to an unlocked residential crisis unit.
- B. inpatient hospitalization on a locked unit.
- C. attending a day treatment program for 4 weeks.
- D. admission to a partial hospital program.
Correct Answer: B
Rationale: The correct answer is B: inpatient hospitalization on a locked unit. This option is the most appropriate given the patient's presentation. The patient is experiencing severe positive symptoms of schizophrenia, such as delusions and disorganized behavior, posing a risk to himself and others by expressing intent to obtain a gun. Additionally, the patient is neglecting basic needs, indicating a need for close monitoring and intervention. Inpatient hospitalization on a locked unit provides a structured and secure environment for intensive treatment, ensuring safety and stabilization.
Incorrect choices:
A: Admission to an unlocked residential crisis unit may not provide the level of monitoring and security needed for a patient with active psychotic symptoms and self-harm potential.
C: Attending a day treatment program for 4 weeks does not address the acute safety concerns and level of impairment displayed by the patient.
D: Admission to a partial hospital program may not offer the round-the-clock supervision and immediate intervention required for someone at risk of harming themselves or others.