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Which remarks by a 72-year-old patient should prompt the nurse to assess for depression? Select one tha does not apply.
- A. Lately I have had a lot of aches and pains and just havent felt very well.
- B. People are in and out of my room all day and all night taking my things.
- C. Dont ask me to eat. I cant because my stomach is upset all the time.
- D. Im eating more than usual, and I am sleeping about 6 hours a night.
Correct Answer: D
Rationale: Somatic symptoms (A), delusions of persecution (B), and nihilistic delusions (C) are common in late-onset depression, warranting assessment. Increased appetite and contentment (D, E) do not suggest depression.
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An 11-year-old boy stays home from school to care for his siblings while his mother works, because the family cannot afford a babysitter. During the community mental health nurse's visit, he reveals that he thinks his father does not like him because he calls him 'stupid' all the time. He states he is too dumb to learn much and has no friends at school because he does not deserve them. Which nursing diagnosis should be the priority for the child?
- A. Helplessness
- B. Knowledge deficit
- C. Ineffective coping
- D. Chronic low self-esteem
Correct Answer: D
Rationale: The correct answer is D: Chronic low self-esteem. This diagnosis is appropriate because the child displays a negative self-concept, feeling unworthy, lacking confidence, and believing he is "stupid" and undeserving of friends. This impacts his self-worth and psychological well-being. Chronic low self-esteem is the priority to address as it affects various aspects of his life.
Choice A: Helplessness may seem relevant due to the family situation, but the child's core issue is more about self-worth than feeling helpless in his situation.
Choice B: Knowledge deficit is not the priority as the child's issue lies more in his emotional well-being rather than lack of information.
Choice C: Ineffective coping might be a concern, but the root of his struggles is his self-esteem, making chronic low self-esteem the primary focus.
Which of the following is a priority nursing intervention for a patient with anorexia nervosa during the refeeding process?
- A. Encourage the patient to engage in physical activity to stimulate appetite.
- B. Monitor vital signs and electrolyte levels to avoid refeeding syndrome.
- C. Offer high-calorie snacks to speed up weight gain.
- D. Focus on the patient's body image concerns before addressing nutrition.
Correct Answer: B
Rationale: The correct answer is B because monitoring vital signs and electrolyte levels is crucial during the refeeding process to prevent refeeding syndrome, a potentially life-threatening complication. This intervention ensures early detection of any electrolyte imbalances or cardiac complications that may arise as the body readjusts to increased food intake. Encouraging physical activity (A) can be harmful due to the patient's compromised state. Offering high-calorie snacks (C) may lead to rapid weight gain and increase the risk of refeeding syndrome. Focusing on body image concerns (D) is important but should not take precedence over addressing the patient's immediate medical needs.
A nurse interviews a patient abducted and raped at gunpoint by an unknown assailant. The patient says, "I can't talk about it. Nothing happened. I have to forget."Â What is the patient's present coping strategy?
- A. Somatization
- B. Repression
- C. Projection
- D. Denial
Correct Answer: D
Rationale: The correct answer is D: Denial. The patient's statement of "I can't talk about it. Nothing happened. I have to forget" indicates a denial coping strategy. Denial is a defense mechanism where individuals refuse to acknowledge a stressful situation or event. In this case, the patient is attempting to block out the traumatic experience of being abducted and raped by denying its existence. This coping mechanism helps the individual temporarily avoid the emotional distress associated with the event.
A: Somatization involves expressing emotional distress through physical symptoms, which is not evident in the patient's statement.
B: Repression is the unconscious blocking of unpleasant memories, whereas the patient is consciously trying to forget the event.
C: Projection involves attributing one's own thoughts or feelings to others, which is not demonstrated in the patient's statement.
In summary, the patient's use of denial as a coping strategy is evident in their attempt to minimize the traumatic experience by refusing to acknowledge it.
A high school cheerleader was admitted to the eating disorders unit, having developed hypokalemia as the result of purging. Which of these medications will probably be prescribed for the client?
- A. Potassium.
- B. Calcium gluconate.
- C. Metoclopramide (Reglan).
- D. Ferrous sulfate.
Correct Answer: A
Rationale: Step 1: The client has hypokalemia, indicating low potassium levels due to purging.
Step 2: Potassium is essential for muscle function, including the heart.
Step 3: Correct Answer: A - Potassium will be prescribed to replenish the deficient levels.
Summary: B is incorrect as calcium gluconate is not used to treat hypokalemia. C and D are unrelated to treating low potassium levels.
A patient has acute anxiety related to an automobile accident 2 hours ago. The patient needs teaching about drugs from which group?
- A. Tricyclic antidepressants
- B. Antipsychotic drugs
- C. Antimanic drugs
- D. Benzodiazepines
Correct Answer: D
Rationale: The correct answer is D: Benzodiazepines. Benzodiazepines are commonly used in the treatment of acute anxiety due to their rapid onset of action and effectiveness in managing symptoms such as panic attacks. They work by enhancing the inhibitory neurotransmitter GABA, leading to sedative and anxiolytic effects. Tricyclic antidepressants (Choice A) are not the first-line treatment for acute anxiety. Antipsychotic drugs (Choice B) are primarily used for conditions such as schizophrenia and bipolar disorder, not acute anxiety. Antimanic drugs (Choice C) are used to manage symptoms of mania in conditions like bipolar disorder, not acute anxiety. Therefore, the correct choice is Benzodiazepines due to their rapid efficacy and established role in managing acute anxiety.