Nokea
Which statement by a 16-year-old is considered as positive evidence that the family’s involvement in therapy is moving them towards effective functioning?
- A. “My dad has finally stopped giving me advice on how to live my life.”
- B. “I stopped playing football since practice required me to be away from home so often.”
- C. “Since my mother quit her job, she is more available to keep the home running smoothly.”
- D. “Eating dinner with my parents on Sunday nights has helped us be more aware of each other’s needs.”
Correct Answer: D
Rationale: The correct answer is D because it shows positive evidence of improved family dynamics through increased communication and awareness of each other's needs. Eating dinner together signifies a commitment to spending quality time and fostering connections. Choice A indicates a lack of interference but not necessarily improved functioning. Choice B suggests withdrawal from activities, which may not be positive. Choice C implies a sacrifice that may not directly lead to effective functioning.
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When asked, the nurse explains that “grief work” refers to:
- A. Establishing new methods of coping with stress
- B. Evaluating progress made toward accepting the loss
- C. The means by which one moves through the grief process
- D. Actively seeking assistance to cope with the loss.
Correct Answer: C
Rationale: The correct answer is C because "grief work" refers to the psychological process of actively working through and resolving the emotions and thoughts associated with a loss. This involves facing and processing the feelings of grief rather than avoiding them, ultimately leading to acceptance and healing. Choice A is incorrect as it focuses on coping with stress, not specifically grief. Choice B is incorrect as it emphasizes evaluating progress rather than the process of grieving itself. Choice D is incorrect as it pertains to seeking assistance, which is a part of coping but not the definition of grief work.
A patient begins a new program to assist with building social skills. In which part of the plan of care should a nurse record the item, Encourage patient to attend one psychoeducational group daily?
- A. Assessment
- B. Implementation
- C. Analysis
- D. Evaluation
Correct Answer: B
Rationale: The correct answer is B: Implementation. In the nursing process, implementation involves putting the plan of care into action. Encouraging the patient to attend a psychoeducational group daily is an action that is carried out as part of the plan to build social skills. This step focuses on executing interventions to achieve the desired outcomes. In contrast, assessment (A) involves collecting data, analysis (C) involves interpreting data, and evaluation (D) involves determining the effectiveness of interventions. Therefore, the correct placement for recording this item is in the implementation phase.
A community health nurse visits an elderly person whose spouse died 6 months ago. Two vodka bottles are in the trash. When the nurse asks about alcohol use, this person says, “I get lonely and drink a little to help me forget.” Select the nurse’s most therapeutic intervention.
- A. Assess whether this patient is drinking and driving.
- B. Teach the person about risks for alcoholism and suggest other coping strategies
- C. Advise the person not to drink alone because the risks for injury increase.
- D. Arrange for the person to attend an Alcoholics Anonymous meeting for older adults.
Correct Answer: B
Rationale: The correct answer is B: Teach the person about risks for alcoholism and suggest other coping strategies. This intervention is the most therapeutic because it addresses the underlying issue of using alcohol as a coping mechanism for loneliness and grief. By educating the person about the risks of alcoholism, the nurse can help the individual understand the potential harm of their current coping strategy. Additionally, suggesting alternative coping strategies can provide healthier ways to deal with loneliness and grief, ultimately promoting better overall well-being.
Choice A is incorrect because while assessing drinking and driving is important, it does not directly address the underlying emotional reasons for the alcohol use.
Choice C is incorrect as it focuses on the risks of injury rather than addressing the emotional aspects of the person's drinking behavior.
Choice D is incorrect as it jumps to a specific intervention without first addressing the person's understanding of their alcohol use and providing alternative coping strategies.
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.
A health care provider writes these new prescriptions for a resident in a skilled nursing facility: 2 G sodium diet, Restraint as needed, Limit fluids to 1800 mL daily, Continue antihypertensive medication, Milk of magnesia 30 mL PO once if no bowel movement for 3 days. The nurse should:
- A. Question the fluid restriction.
- B. Question the order for restraint.
- C. Transcribe the prescriptions as written.
- D. Assess the resident’s bowel elimination
Correct Answer: A
Rationale: Step 1: Fluid restriction of 1800 mL may not be appropriate for all residents in a skilled nursing facility. Step 2: Excessive fluid restriction can lead to dehydration, especially in elderly residents. Step 3: It is crucial for the nurse to question the fluid restriction to ensure it is safe for the resident. Therefore, the correct answer is A.
Summary:
- Option A is correct as questioning the fluid restriction is essential for the resident's safety.
- Option B is incorrect as restraining a resident should only be used as a last resort and should be questioned if not necessary.
- Option C is incorrect as blindly transcribing without assessing appropriateness can be harmful.
- Option D is incorrect as assessing bowel elimination is important but addressing the fluid restriction is more urgent in this scenario.