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About an hour after the patient has ECT, he complains of having a headache. The nurse should:
- A. Notify the physician stat.
- B. Administer an as needed (prn) dose of acetaminophen.
- C. Take the patient through a progressive relaxation sequence.
- D. Advise going to activities to expend energy and relieve tension.
Correct Answer: B
Rationale: The correct answer is B: Administer an as needed (prn) dose of acetaminophen. After ECT, it is common for patients to experience headaches as a side effect. Administering acetaminophen will help alleviate the headache and provide relief for the patient. It is important to address the patient's discomfort promptly and effectively.
Choice A is incorrect because headaches after ECT are a common side effect and do not typically require immediate physician notification. Choice C is incorrect as progressive relaxation may not address the immediate headache symptoms. Choice D is also incorrect as physical activities may exacerbate the headache rather than provide relief. Administering acetaminophen is the most appropriate and efficient intervention in this situation.
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Which activities should the nurse evaluate in an assessment of an older patient’s functional status? (Select all that apply.)
- A. Possessing the ability to prepare nutritious meals independently.
- B. Having the financial resources available to live independently
- C. Performing regular, simple maintenance on their primary residence.
- D. Effectively toileting themselves for both bowel and bladder elimination.
Correct Answer: A,C
Rationale: The correct answers are A and C. A nurse should evaluate if the older patient can prepare nutritious meals independently, as this indicates their ability to meet basic nutritional needs and maintain independence in daily living. Additionally, assessing if the patient can perform regular, simple maintenance on their primary residence is important for gauging their ability to live safely and comfortably. Choices B and D are incorrect as financial resources and toileting abilities, while important, do not directly reflect functional status in the same way as meal preparation and home maintenance.
How can the nurse encourage an extremely shy patient to participate therapeutically in a dance activity group?
- A. Offer to dance with the patient.
- B. Ask the patient if this is the first dance he has attended.
- C. Sit with the patient away from the group.
- D. Encourage another patient to ask him to dance.
Correct Answer: A
Rationale: The correct answer is A because offering to dance with the patient shows support, builds trust, and models behavior. This approach can help the shy patient feel more comfortable and encouraged to participate. Choice B focuses on the patient's past experience, which may not directly address the current issue. Choice C isolates the patient, potentially increasing feelings of shyness. Choice D involves a third party, which may not be as effective in building a direct connection with the shy patient. Overall, option A is the most effective in directly engaging and encouraging the shy patient to participate therapeutically in the dance activity group.
When a hospitalized patient dies, his wife stares blankly and states, "It can’t be." This indicates:
- A. Despair and protest
- B. Shock and disbelief
- C. Anger and hostility
- D. Disorganization and confusion
Correct Answer: B
Rationale: Correct Answer: B (Shock and disbelief)
Rationale:
1. The wife's blank stare and statement "It can’t be" suggest a state of disbelief and being stunned by the news of her husband's death, indicating shock.
2. Shock is a common initial reaction to unexpected and distressing events, such as the sudden death of a loved one.
3. This choice is the most fitting based on the wife's reaction of disbelief and being unable to accept the reality of the situation.
Summary:
A: Despair and protest - Despair involves a sense of hopelessness, not evident in the wife's initial reaction. Protest implies a more active response, while the wife's reaction is passive.
C: Anger and hostility - There is no indication of anger or hostility in the wife's initial response; rather, it is characterized by disbelief.
D: Disorganization and confusion - While the wife may feel disorganized and confused later, her initial response reflects more shock and disbelief than disorganization
Which intervention would qualify as primary prevention of violent behaviors in children and adolescents?
- A. Forbidding the child to continue friendships with violent peers
- B. Limiting exposure to violence on TV, video, and computer games
- C. Seeking counseling for a child who has been experimenting with drugs
- D. Showing a unified approach to parenting when dealing with a violent child
Correct Answer: B
Rationale: The correct answer is B because limiting exposure to violence on TV, video, and computer games falls under primary prevention by addressing risk factors before violent behaviors occur. This intervention helps reduce the likelihood of children and adolescents developing violent tendencies by minimizing their exposure to violent content that can influence their behavior.
A: Forbidding the child to continue friendships with violent peers is more of a secondary prevention strategy targeting existing risk factors, not primary prevention.
C: Seeking counseling for a child who has been experimenting with drugs is also a secondary prevention strategy focusing on addressing a specific risk factor, not primary prevention.
D: Showing a unified approach to parenting when dealing with a violent child is a tertiary prevention strategy aimed at managing and reducing harm after the behavior has already occurred, not primary prevention.
Which statement made by a patient just prior to being transported for a scheduled ECT treatment would result in cancellation of the treatment?
- A. “Will I remember having this treatment?”
- B. “Did eating some crackers cause any problems?”
- C. "Is this going to help me feel better soon?"
- D. "I feel like I need to ask more questions about the procedure."
Correct Answer: A
Rationale: The correct answer is A because asking about memory loss indicates a lack of informed consent and understanding of ECT procedure. Memory loss is a common side effect of ECT, and a patient should be well-informed about it before treatment. Choices B, C, and D do not raise concerns about the patient's understanding or readiness for ECT, making them incorrect. Choice B asks about dietary concerns, which do not directly impact the treatment. Choice C shows the patient's hope for improvement, which is a positive attitude. Choice D indicates the patient's desire for more information, which is a sign of engagement in their care.