Nokea
Which response by the nurse to a Korean American daughter caring for her aged father would best reflect an understanding of the family's culture?
- A. "Being expected to care for one's family can be a significant burden to bear."Â
- B. "You seem very tired. Respite care for a day or two each week might help you."Â
- C. "Caring for a loved one in need can be both a great honor and a great challenge."Â
- D. "There is a very nice nursing home not far from here. Your father might like it there."Â
Correct Answer: C
Rationale: The correct answer is C because it acknowledges the dual nature of caregiving in Korean American culture - as both an honor and a challenge. This response shows cultural sensitivity by recognizing the cultural values of respect for elders and familial duty. Choice A could be seen as negative and judgmental. Choice B, while offering a practical solution, doesn't address the cultural aspects of caregiving. Choice D may be perceived as insensitive and dismissive of the importance of family in Korean culture. Overall, choice C demonstrates empathy and understanding of the family's cultural values, making it the best response.
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Which information would be of greatest assistance to a nurse assessing a patient's motivation to change behavior associated with maladaptive eating regulation responses?
- A. The number, on a scale of 1 to 10, that reflects the patient's desire for treatment.
- B. The name of a person the patient feels he or she can rely on for emotional support.
- C. The advantages the patient identifies as motivation for controlling the maladaptive behavior.
- D. The reasons the patient identifies as the factors that originally caused the maladaptive behavior.
Correct Answer: A
Rationale: The correct answer is A because assessing the patient's desire for treatment provides insight into their readiness and motivation to change behavior. This information indicates their willingness to engage in the treatment process and is a key factor in predicting behavior change.
Option B is incorrect because relying on emotional support may not necessarily reflect the patient's motivation to change their behavior. Option C is incorrect as identifying advantages for controlling maladaptive behavior does not directly address the patient's motivation level. Option D is incorrect because understanding the factors that caused the behavior does not necessarily indicate the patient's current motivation to change.
A newly admitted patient diagnosed with paranoid schizophrenia is hypervigilant and constantly scans the environment. He states that he saw two doctors talking in the hall and knows they were plotting to kill him. When charting, how should the nurse identify this behavior?
- A. Idea of reference
- B. Delusion of infidelity
- C. Auditory hallucination
- D. Echolalia
Correct Answer: A
Rationale: The correct identification for the behavior described is "A: Idea of reference." This term refers to the belief that neutral events are directed at oneself. In this case, the patient's belief that the doctors were plotting to kill him is an example of a false idea of reference. Delusion of infidelity (choice B) involves false beliefs about a partner's unfaithfulness, not relevant here. Auditory hallucination (choice C) pertains to false perceptions of hearing sounds, not applicable. Echolalia (choice D) is the repetition of words spoken by others, not seen in this scenario. Identifying the behavior as an idea of reference helps the nurse understand the patient's distorted perception of reality.
When analyzing the behaviors of a 23-year-old who meets the criteria for antisocial personality disorder, the nurse recognizes that the following nursing diagnosis would be pertinent to his care:
- A. Risk for self-mutilation
- B. Disturbed personal identity
- C. Impaired social interaction
- D. Social isolation
Correct Answer: C
Rationale: Step-by-step rationale for choice C (Impaired social interaction) being the correct answer:
1. Antisocial personality disorder is characterized by a lack of regard for others and a pattern of violating their rights.
2. Individuals with this disorder often have difficulty forming and maintaining healthy relationships.
3. Impaired social interaction reflects the challenges the individual faces in relating to others.
4. This nursing diagnosis would address the core issue of social dysfunction in individuals with antisocial personality disorder.
Summary of why the other choices are incorrect:
A. Risk for self-mutilation - Not typically associated with antisocial personality disorder, more common in other mental health conditions.
B. Disturbed personal identity - Not a primary concern in antisocial personality disorder, which is more about behavior than identity.
D. Social isolation - While individuals with antisocial personality disorder may isolate themselves, impaired social interaction is a more direct and specific issue to address in their care.
For those family members who desire to care at home for loved ones who have been given a diagnosis of Alzheimer's disease, it is important for the nurse to ensure that the family is aware of which caregiver skills and responsibilities will be necessary. What is one of the responsibilities of the caregiver during the middle stage of the disease?
- A. Helping the loved one with memory and communication problems
- B. Providing a stable, routine environment
- C. Providing complete assistance with physical care
- D. Adapting to the changing personality and behavior of the loved one
Correct Answer: D
Rationale: The correct answer is D: Adapting to the changing personality and behavior of the loved one. During the middle stage of Alzheimer's disease, individuals may experience significant changes in personality and behavior. Caregivers need to adapt to these changes by being patient, understanding, and flexible. This responsibility is crucial for maintaining a positive and supportive relationship with the loved one.
A: Helping the loved one with memory and communication problems is important, but it is more relevant in the early stages of the disease when these issues are more prominent.
B: Providing a stable, routine environment is essential throughout all stages of Alzheimer's disease, not just the middle stage.
C: Providing complete assistance with physical care may become necessary in the later stages of the disease when the individual's physical abilities decline significantly.
The nurse working with a client whose diagnosis is bulimia asks the client to recall a time in her life when eating was a positive experience and she enjoyed small amounts of food without purging. The purpose of this intervention is to:
- A. gain additional information about the client's bulimic condition.
- B. emphasize that the client is capable of engaging in eating without purging.
- C. incorporate specific foods into the meal plan to reflect pleasant memories.
- D. assist the client to become more compliant with the treatment plan.
Correct Answer: B
Rationale: The correct answer, B, emphasizes that the client is capable of engaging in eating without purging. By asking the client to recall a positive experience with food, the nurse is helping the client recognize that they can enjoy food without the need to purge. This intervention aims to challenge the client's negative beliefs about food and eating, promoting a healthier relationship with food.
Choice A is incorrect as the purpose is not solely to gain additional information about the client's condition but rather to shift the client's perspective on food. Choice C is incorrect as the intervention focuses on emotional aspects rather than specific foods. Choice D is incorrect as the goal is to address the psychological aspect of the client's behavior, not just compliance with the treatment plan.