Nokea
Which remark by one of the grief support group members would the nurse interpret as indicating unresolved feelings of guilt?
- A. The Christmas season is always a sad time for me.
- B. I know that my husband had a good life.
- C. It seems I miss my son more as time goes on.
- D. I am still wishing I had gotten help to him sooner.
Correct Answer: D
Rationale: The correct answer is D because expressing a wish for getting help sooner implies a sense of responsibility and guilt for not doing so. This indicates unresolved feelings of guilt. Choice A refers to sadness during a specific time of the year, not guilt. Choice B reflects acceptance and closure. Choice C indicates a natural progression of grief, not necessarily guilt.
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Which intervention will the nurse planning care for a patient with acute grief implement?a. Providing information about the grief process
- A. Providing information about the grief process.
- B. Suggesting utilization of community resources in a few weeks
- C. Encouraging dependence on the nurse for support
- D. Assessing for signs of complicated grief or depression
Correct Answer: A
Rationale: The correct answer is A because providing information about the grief process helps the patient understand their feelings and reactions, promoting emotional healing. Choice B is incorrect because suggesting community resources may not address the patient's immediate needs. Choice C is incorrect as encouraging dependence on the nurse may hinder the patient's ability to cope independently. Choice D is incorrect because assessing for complicated grief or depression is important but not the initial intervention in planning care for acute grief.
Which assessment observation supports a patient’s diagnosis of disorganized schizophrenia?
- A. Reports suicidal ideations
- B. Last relapse was 6 years ago
- C. Consistent inappropriate laughing
- D. Believes that the government is out to get me
Correct Answer: C
Rationale: The correct answer is C because consistent inappropriate laughing is a characteristic symptom of disorganized schizophrenia. This observation aligns with the disorganized behavior and affect commonly seen in this subtype of schizophrenia. Option A is not specific to disorganized schizophrenia. Option B does not directly relate to disorganized symptoms. Option D suggests paranoia, which is more indicative of paranoid schizophrenia rather than disorganized schizophrenia.
An adult patient shares that, When my mother died when we were children, I never saw my
father show any emotion. What do you think will happen with those unexpressed feelings?
Which response is most appropriate?
- A. Pent-up emotions may lead to depression or other disorders.
- B. Your father probably has worked through his grief by this time.
- C. Maybe you can teach him how to best express his own feelings.
- D. If feelings are not effectively expressed, the person can become suicidal.
Correct Answer: A
Rationale: Step 1: Pent-up emotions are emotions that are suppressed or not expressed.
Step 2: Unexpressed feelings, especially from past traumatic events, can lead to emotional distress.
Step 3: Long-term suppression can manifest as depression or other mental health disorders.
Step 4: Therefore, choice A is the most appropriate response as it highlights the potential negative consequences of unexpressed emotions.
Summary:
- Choice B assumes the father has processed his grief, which may not be the case.
- Choice C oversimplifies the complexity of emotional expression and may not address the root issue.
- Choice D jumps to an extreme outcome without considering the range of possible consequences.
Immediately after electroconvulsive therapy (ECT), nursing care of the patient is most similar to care of a patient:
- A. With delirium tremens
- B. Recovering from conscious sedation
- C. With acute alcohol withdrawal
- D. Undergoing a routine diagnostic procedure
Correct Answer: B
Rationale: The correct answer is B: Recovering from conscious sedation. After ECT, patients are closely monitored as they recover from anesthesia and sedation. Nursing care involves assessing vital signs, mental status, and ensuring the patient's safety. This is similar to caring for a patient recovering from conscious sedation, where monitoring and observation are essential.
A: Delirium tremens involves severe alcohol withdrawal symptoms, which require specialized care including managing agitation and hallucinations.
C: Acute alcohol withdrawal requires specific interventions such as monitoring for seizures and providing medications to prevent complications.
D: Routine diagnostic procedures do not typically involve sedation or anesthesia, so the level of monitoring and care needed is different from post-ECT care.
A newly admitted patient diagnosed with major depression has gained 20 pounds over a few months and has suicidal ideation. The patient has taken an antidepressant medication for 1 week without remission of symptoms. Select the priority nursing diagnosis.
- A. Imbalanced nutrition: more than body requirements.
- B. Chronic low self-esteem.
- C. Risk for suicide.
- D. Hopelessness.
Correct Answer: C
Rationale: The priority nursing diagnosis in this case is C: Risk for suicide. This is because the patient is exhibiting suicidal ideation, which poses an immediate threat to their safety and well-being. Suicidal ideation requires urgent intervention to ensure the patient's safety. The patient's major depression, weight gain, and lack of symptom remission from the antidepressant medication further emphasize the seriousness of the situation. Choices A, B, and D are not the priority in this scenario as they do not address the immediate risk of harm to the patient. Imbalanced nutrition and chronic low self-esteem are important concerns but do not take precedence over the risk of suicide. Hopelessness, while relevant, is not as urgent as addressing the immediate risk of suicide.