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Which response by the nurse would best assist a patient in de-escalating aggressive behavior?
- A. "Tell me what’s going on."
- B. "Why are you getting so upset?"
- C. "If you throw something, you will be restrained."
- D. "It’s time for group therapy. You can talk there."
Correct Answer: A
Rationale: The correct answer is A because it demonstrates active listening and shows empathy towards the patient, which can help them feel heard and understood. By inviting the patient to express their feelings and concerns, the nurse can help de-escalate the situation by addressing the underlying issues.
Choice B is incorrect because it may come across as confrontational and could further provoke the patient's aggression. Choice C is also incorrect as it threatens the patient with consequences, which can escalate the situation. Choice D is not appropriate as it distracts from addressing the current issue of aggression and may not be well-received by the patient in that moment.
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What is the primary reason for the nurse to have an understanding of the various types of activity and adjunct therapies?
- A. The nurse chooses the most cost-effective therapy group.
- B. The nurse is expected to encourage patients’ involvement in the therapies.
- C. The nurse is responsible for placing the patient in the appropriate group.
- D. The nurse needs to be supportive of the treatment team members who direct these therapies.
Correct Answer: B
Rationale: The correct answer is B because nurses are expected to encourage patients' involvement in therapies to promote holistic care and enhance patient outcomes. By understanding different types of therapies, nurses can educate and motivate patients to participate actively in their treatment plans. This empowers patients to take control of their health and improve their overall well-being. Choices A, C, and D are incorrect because the primary role of the nurse in this context is to support and advocate for the patients' engagement in therapies, rather than focusing on cost-effectiveness, placement, or support of other team members.
Planning for a patient with Asperger's disorder will be facilitated if the nurse understands that this disorder is different from autism. The nurse will base care on knowledge that Asperger's disorder is characterized by:
- A. Repetitive patterns of behavior
- B. Age-appropriate language development.
- C. Stereotypic movements and speech patterns
- D. Obsession with objects that move in a spinning motion
Correct Answer: B
Rationale: The correct answer is B: Age-appropriate language development. Asperger's disorder is characterized by normal to above-average language development, whereas autism typically presents with delays or impairments in language skills. This is important for planning care as it influences communication strategies and interventions for individuals with Asperger's.
A: Repetitive patterns of behavior are more indicative of autism, not specific to Asperger's.
C: Stereotypic movements and speech patterns are also more associated with autism and not a defining feature of Asperger's.
D: Obsession with objects that move in a spinning motion is a specific behavior that may be seen in some individuals with autism, but it is not a defining characteristic of Asperger's disorder.
Family and friends rush to offer support to a friend who has lost her teenage son. Which of these persons, through an intended act of kindness, may contribute to prolonging the woman’s grief?
- A. The physician who prescribed antianxiety agents
- B. The nurse who offered to spend the night at her home
- C. The next-door teenager who provided care for the son’s pet
- D. The accountant who assisted with stabilizing financial affairs.
Correct Answer: A
Rationale: The correct answer is A because prescribing antianxiety agents may mask the woman's grief instead of allowing her to process and work through it naturally. This could potentially prolong her grief by avoiding the necessary emotional processing. The other choices, B, C, and D, all involve support that can help the woman cope with her loss in a healthy way. B offers emotional support and companionship, C helps with practical tasks, and D provides assistance in managing practical matters, all of which can facilitate the grieving process rather than prolong it.
Which intervention will the nurse implement in the first half hour after the patient has received ECT?
- A. Continually stimulate patient to respond, using physical and verbal means.
- B. Continue bagging patient to improve respiratory function until patient is responsive for 10 minutes.
- C. Reorient as necessary to time, place, and person as level of consciousness improves.
- D. Encourage walking and eating breakfast as quickly as possible.
Correct Answer: C
Rationale: The correct answer is C because reorienting the patient to time, place, and person is crucial in the immediate post-ECT period to help the patient regain orientation as consciousness improves. This intervention helps prevent confusion and disorientation commonly experienced after ECT. A: Continually stimulating the patient may be overwhelming and unnecessary. B: Continuing bagging is not relevant after ECT as the patient's respiratory function should have stabilized. D: Encouraging walking and eating can be unsafe immediately post-ECT due to potential disorientation and muscle weakness.
What is the priority nursing diagnosis for a catatonic patient?
- A. Ineffective coping
- B. Impaired physical mobility
- C. Risk for deficient fluid volume
- D. Impaired social interaction
Correct Answer: C
Rationale: The priority nursing diagnosis for a catatonic patient is Risk for deficient fluid volume (C) because catatonic patients are at risk for dehydration due to decreased fluid intake or inability to meet fluid needs. This diagnosis takes precedence over others as dehydration can lead to serious complications. Ineffective coping (A) may be secondary to the catatonic state but addressing fluid volume is more urgent. Impaired physical mobility (B) and Impaired social interaction (D) are important but not as critical as addressing the risk of dehydration in a catatonic patient.