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 teen is grieving the loss of her pet dog. She states to her mother, “I miss my dog so much, but I know that if I start crying, I will never stop.” The teen is expressing a fear of:
- A. Appearing emotionally immature
- B. Embarrassing herself by crying in public
- C. Losing the support of her friends and family.
- D. Losing control over her emotions.
Correct Answer: D
Rationale: The correct answer is D: Losing control over her emotions. The teen's statement indicates a fear of losing control if she starts crying. This fear suggests that she believes crying will lead to an inability to stop, indicating a concern about managing her emotions. This fear of losing control over her emotions aligns with the teen's hesitance to express her grief through tears.
A: Appearing emotionally immature - This choice is incorrect as the teen's statement does not directly suggest a fear of appearing emotionally immature.
B: Embarrassing herself by crying in public - This choice is incorrect as the teen's statement does not mention a fear of embarrassment.
C: Losing the support of her friends and family - This choice is incorrect as the teen's statement does not indicate a fear of losing support from others.
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.
The nurse determines that the most effective point of intervention for bereavement is:
- A. Promotion of mental and spiritual health across the life span
- B. At the time a newly discovered loss is impending
- C. Immediately after the loss has occurred
- D. When requested by the patient
Correct Answer: A
Rationale: The correct answer is A because promoting mental and spiritual health across the lifespan addresses bereavement proactively by providing support and resources before, during, and after losses occur. This approach allows individuals to build resilience and cope effectively with grief. Choice B is incorrect as it focuses on impending loss, missing the opportunity for early intervention. Choice C is incorrect as immediate intervention may not be suitable for everyone and may overlook the importance of ongoing support. Choice D is incorrect as waiting for the patient to request intervention may delay support and hinder the healing process.
A nurse is using Piaget’s model to assess a child’s developmental stage. Which behaviors would determine that a child is successfully achieving the skills required of the formal operations level of development? (Select all that apply.)
- A. Becomes sad when the family pet dies.
- B. Plans a trip to attend a basketball game.
- C. Identifies two different bowls that hold 1 cup.
- D. Selects the appropriate clothing for a ski trip.
Correct Answer: B, D
Rationale: In Piaget's formal operations stage, children develop abstract thinking, planning abilities, and logical reasoning. Planning a trip and selecting appropriate clothing demonstrate these skills. Becoming sad over the pet's death and identifying objects by capacity are more related to emotional and concrete operational stages.
Nursing preparation for a client undergoing electroconvulsive therapy (ECT) resemble those used for general anesthesia. The nurse should follow these steps for this procedure (place in the order they will occur):
- A. Monitor the patients vital signs before the procedure.
- B. Medicate as prior to procedure if ordered.
- C. Educate patient and patients family.
- D. Check a signed consent
Correct Answer: C
Rationale: Rationale:
1. Educating the patient and family is crucial as it helps alleviate anxiety and ensures informed consent.
2. Monitoring vital signs (A) should be done before, during, and after the procedure, not necessarily in a specific order.
3. Medication administration (B) should be based on physician's orders but is not the initial step.
4. Checking a signed consent (D) is important but typically done before proceeding with any procedure, not necessarily in a specific order.
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