Nokea
Which physical disturbance is commonly assessed in patients experiencing acute grief?
- A. Tightness in the chest
- B. Hypersomnia
- C. Increased appetite
- D. Cardiovascular problems
Correct Answer: A
Rationale: The correct answer is A: Tightness in the chest. This physical disturbance is commonly associated with acute grief due to the emotional pain experienced. It is a manifestation of the intense feelings of sadness and loss that accompany grief. Tightness in the chest can be a result of the stress response triggered by grief, leading to physical symptoms such as chest pain and difficulty breathing.
Summary:
B: Hypersomnia and C: Increased appetite are more commonly associated with conditions like depression, while D: Cardiovascular problems may be a long-term consequence of chronic stress but are not typically assessed as a primary physical disturbance in acute grief.
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An older adult patient was diagnosed with schizophrenia at age 18. A nurse at the outpatient medication clinic interviews this patient. Which communication strategy will be most helpful?
- A. Ask questions that can be answered with yes or no.
- B. Use silence often and let the patient take the lead.
- C. Use open-ended, indirect questions.
- D. Ask clear, simple questions using concrete language.
Correct Answer: D
Rationale: The correct answer is D: Ask clear, simple questions using concrete language. This strategy is most helpful because older adults with schizophrenia may have cognitive impairments that affect their ability to process complex information. Clear and simple questions using concrete language can help the patient understand and respond effectively.
Choice A (Ask questions that can be answered with yes or no) limits communication and may not provide enough information for the nurse to assess the patient's condition comprehensively. Choice B (Use silence often and let the patient take the lead) may not be effective as the patient may struggle to communicate effectively due to cognitive impairments. Choice C (Use open-ended, indirect questions) may lead to confusion or misinterpretation for a patient with cognitive challenges.
A nurse assesses four patients between the ages of 70 and 80. Which patient has the highest risk for alcohol abuse? The patient who:
- A. Consumes 1 glass of wine nightly with dinner.
- B. Drank socially throughout adult life and continues this pattern, saying, “I’ve earned the right to do as I please.”
- C. Began drinking alcohol daily after retirement and says, “A few drinks keep my mind off my arthritis.”
- D. Abused alcohol between the ages of 25 and 40 but now abstains and occasionally attends Alcoholics Anonymous (AA).
Correct Answer: C
Rationale: The correct answer is C because the patient who started drinking daily after retirement as a coping mechanism for arthritis has the highest risk for alcohol abuse. This behavior indicates a potential dependence on alcohol to manage physical and emotional discomfort, leading to increased consumption and potential addiction.
Choice A is not the correct answer because consuming 1 glass of wine nightly with dinner is generally considered moderate drinking and does not necessarily indicate alcohol abuse.
Choice B is also not the correct answer as social drinking throughout adult life, even if justified as a reward, does not inherently suggest alcohol abuse without further evidence of problematic drinking patterns.
Choice D is incorrect as the patient has a history of alcohol abuse but currently abstains and seeks support through AA, indicating active efforts to maintain sobriety and reduce the risk of alcohol abuse.
An outcome for a patient experiencing anticipatory grieving for a spouse diagnosed with terminal cancer would be that the patient will:
- A. Continue to be emotionally involved with the dying spouse
- B. Develop protective mental mechanisms to allay the pain of spousal loss
- C. Not voice threats of physical violence that is either self or others directed
- D. Agree to stay at home and care for the spouse with appropriate assistance
Correct Answer: A
Rationale: The correct answer is A because anticipatory grieving involves emotional involvement with the dying spouse. This allows the patient to process emotions, express love, and make meaningful connections before the actual loss. Choice B is incorrect as it suggests avoidance of pain through mental mechanisms, which is not conducive to healthy grieving. Choice C is incorrect as it focuses on a specific behavior (violence) rather than the emotional process of grieving. Choice D is incorrect as it assumes the patient's agreement to care for the spouse is the primary outcome, overlooking the emotional aspect of anticipatory grief.
An appropriate intervention for a patient with situational low self-esteem would be:
- A. Providing large muscle activities to relieve stress
- B. Attempting to determine triggers to hallucinations
- C. Engaging patient in activities designed to permit success
- D.
Encouraging verbalization of feelings in a safe environment
Correct Answer: C
Rationale: The correct answer is C because engaging the patient in activities designed to permit success helps boost self-esteem by providing opportunities for achievement. This intervention focuses on building the patient's confidence and self-worth through positive experiences. Choice A is incorrect as it addresses stress relief rather than self-esteem. Choice B is irrelevant as it pertains to hallucinations, not self-esteem. Choice D is also incorrect because while verbalizing feelings is important, it may not directly target the underlying issue of low self-esteem.
A nurse administers pure oxygen to a client during and after electroconvulsive therapy. What is the nurse’s rationale for this procedure?
- A. To prevent increased intracranial pressure resulting from anoxia
- B. To prevent anoxia due to medication-induced paralysis of respiratory muscles
- C. To prevent hypotension, bradycardia, and bradypnea due to electrical stimulation
- D. To prevent blocked airway resulting from seizure activity
Correct Answer: B
Rationale: The correct answer is B: To prevent anoxia due to medication-induced paralysis of respiratory muscles. During electroconvulsive therapy, muscle relaxants are often used to prevent injury during the seizure. These medications can lead to paralysis of respiratory muscles, causing potential anoxia if oxygen is not administered. Providing pure oxygen ensures adequate oxygenation despite muscle paralysis.
Incorrect Choices:
A: Preventing increased intracranial pressure is not the primary rationale for administering oxygen during ECT.
C: Hypotension, bradycardia, and bradypnea are potential side effects of ECT itself, but oxygen administration is not primarily to prevent these.
D: Oxygen is not administered to prevent a blocked airway but rather to ensure adequate oxygenation during muscle paralysis.