Nokea
Which statement best defines the nurse’s initial role as the patient’s source of help in addressing interpersonal problems?
- A. “I’ll work with your doctor to help you get better.”
- B. “I’ll be working with you to help solve your marital troubles.”
- C. “Your medications will help you feel better as soon as they take effect.”
- D. To direct the patient to other professionals for addressing interpersonal issues
Correct Answer: B
Rationale: The correct answer is B because it emphasizes the nurse's role in actively working with the patient to address interpersonal problems. The nurse's initial role is to provide support and assistance to the patient in resolving their issues collaboratively. Choice A focuses on medical treatment and collaboration with the doctor, not specifically addressing interpersonal problems. Choice C solely emphasizes the role of medications in improving the patient's well-being, neglecting the interpersonal aspect. Choice D suggests passing off the responsibility to other professionals, which contradicts the nurse's initial role as a source of help for the patient. In summary, choice B is correct because it highlights the nurse's active involvement in solving the patient's interpersonal problems.
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A young woman had just learned of the accidental death of her husband. She begins to cry
and states, Its not fair! How could he do this to me? This remark is assessed as:
- A. A plea for help
- B. An explosive episode
- C. An expression of anger
- D. Fear of making decisions alone
Correct Answer: C
Rationale: The correct answer is C, an expression of anger. The woman's statement "It's not fair! How could he do this to me?" indicates feelings of anger and resentment towards her husband for leaving her unexpectedly. This response does not show a plea for help (A), as she is expressing her emotions rather than seeking assistance. It is also not an explosive episode (B) as there is no indication of sudden outbursts or intense emotional reactions. Similarly, it is not about fear of making decisions alone (D) as her statement focuses on her feelings of unfairness and betrayal. In summary, the woman's remark reflects her anger and sense of injustice following her husband's accidental death.
A patient diagnosed with major depression has lost 20 pounds in one month, has chronic low self-esteem, and a plan for suicide. The patient has taken an antidepressant medication for 1 week. Which nursing intervention has the highest priority?
- A. Implement suicide precautions.
- B. Offer high-calorie snacks and fluids frequently
- C. Assist the patient to identify three personal strengths.
- D. Observe the patient for therapeutic effects of antidepressant medication.
Correct Answer: A
Rationale: The correct answer is A: Implement suicide precautions. This is the highest priority because the patient has a plan for suicide, which poses an immediate risk to their safety. Implementing suicide precautions involves ensuring the patient's environment is safe, removing any potential means of self-harm, and closely monitoring the patient to prevent any suicide attempts.
Choice B is incorrect because offering high-calorie snacks and fluids frequently addresses the physical aspect of weight loss but does not address the immediate safety concern of suicide.
Choice C is incorrect because assisting the patient to identify personal strengths is important for building self-esteem but is not the highest priority when the patient is at risk for suicide.
Choice D is incorrect because observing the patient for therapeutic effects of antidepressant medication is important but not as urgent as ensuring the patient's safety in the case of suicidal ideation.
A patient is scheduled to attend an occupational therapy group to work on the identified goal of “recognizing and using more effective coping techniques.” What measure can the nurse use to continue to support the patient’s attainment of this goal after he returns to the unit?
- A. Praising him for positive behavioral changes
- B. Avoiding setting limits that would increase his anxiety level
- C. Isolating him from more seriously ill patients
- D. Recommending that he avoid group activities for a while
Correct Answer: A
Rationale: The correct answer is A: Praising him for positive behavioral changes. This measure reinforces the patient's use of effective coping techniques, providing positive feedback and motivation. This positive reinforcement encourages the patient to continue utilizing these strategies.
Choices B, C, and D are incorrect:
B: Avoiding setting limits that would increase his anxiety level - This does not actively support the patient's goal of recognizing and using more effective coping techniques.
C: Isolating him from more seriously ill patients - Isolation does not promote the practice of coping techniques and may hinder the patient's social interaction and progress.
D: Recommending that he avoid group activities for a while - Avoiding group activities contradicts the goal of attending occupational therapy groups and working towards improved coping techniques.
Which nursing intervention supports the principles on which the cross-links theory of aging is based?
- A. Applying an elastin-sustaining moisturizer to an adult patient’s skin
- B. Assessing a patient’s family history for genetic diseases and disorders
- C. Questioning a patient about long-term exposure to environmental toxins
- D. Assisting an adult patient in selecting foods high in vitamins A, C, and E
Correct Answer: D
Rationale: The correct answer is D because selecting foods high in vitamins A, C, and E supports the principles of the cross-links theory of aging, which focuses on the accumulation of damage from oxidative stress. Vitamins A, C, and E are antioxidants that help combat oxidative stress and reduce the formation of cross-links in tissues. This intervention can potentially slow down the aging process by reducing cellular damage.
Choice A is incorrect because applying an elastin-sustaining moisturizer does not directly address the oxidative stress aspect of the cross-links theory of aging.
Choice B is incorrect as assessing family history for genetic diseases does not specifically target the mechanisms involved in the cross-links theory of aging.
Choice C is incorrect because questioning about exposure to environmental toxins may be important for overall health but is not directly related to the principles of the cross-links theory of aging.
When making a distinction as to whether an elderly patient has confusion related to delirium or another problem, what information would be of particular value?
- A. Evidence of spasticity or flaccidity
- B. The patient’s level of motor activity
- C. Medications the patient has recently taken
- D. Level of preoccupation with somatic symptoms
Correct Answer: C
Rationale: The correct answer is C: Medications the patient has recently taken. This information is crucial because certain medications can cause symptoms of delirium or exacerbate confusion in elderly patients. By reviewing the patient's recent medications, healthcare providers can identify potential drug-induced causes of confusion and adjust the treatment accordingly.
Choice A (Evidence of spasticity or flaccidity) is incorrect because these symptoms are more related to neurological conditions such as stroke or spinal cord injury, not specifically delirium.
Choice B (The patient’s level of motor activity) is not as relevant in distinguishing delirium from other problems as medication history, as motor activity can be influenced by various factors.
Choice D (Level of preoccupation with somatic symptoms) is also less relevant compared to medication history in differentiating delirium, as somatic symptoms may not always directly indicate the underlying cause of confusion in elderly patients.