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Which statement made by a teenage male hospitalized after a failed suicide attempt is most concerning to the nurse?
- A. The gun I got for my birthday is my most prized possession.
- B. I don’t know why I get so depressed and want to die.
- C. "I don’t feel like I can talk to anyone about my feelings."
- D. The gun I got for my birthday is my most prized possession.
Correct Answer: D
Rationale: This statement is concerning because it suggests the teenager may still have access to dangerous means (in this case, a gun) and may not fully understand or take responsibility for the gravity of his previous suicidal attempt. The attachment to the gun is alarming.
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What milieu factor would need most attention from the nurse who is caring for a patient who has received six ECT treatments and has two more sc\
- A. Therapeutic activities
- B. Boundary maintenance
- C. Safety
- D. Trust attainment
Correct Answer: C
Rationale: When caring for a patient who has received multiple electroconvulsive therapy (ECT) treatments and has more scheduled, the most critical milieu factor that needs attention is safety. ECT is a medical procedure that involves inducing seizures through electrical stimulation, and patients may be at risk of physical harm during or after the treatments. The nurse should prioritize ensuring the patient's safety during and after the ECT sessions, including monitoring for any adverse effects, providing support, and taking necessary precautions to prevent accidents. Safety measures, such as fall prevention protocols and close observation, are essential in the care of patients undergoing ECT to ensure their well-being. Therefore, safety is the milieu factor that requires the most attention in this situation.
A patient is being seen for symptoms of insomnia and significant weight loss that has occurred during the 2 months since her husband’s death. What is the purpose of the query, “Describe how it has been for you since your husband died?”
- A. To display an attitude of concern and sympathy to the patient
- B. To learn whether the patient has a significant support system
- C. To rule out factors that may interfere with diagnosing her illness
- D. To determine the risk for pathologic grief and the need for grief therapy
Correct Answer: D
Rationale: The purpose of the query "Describe how it has been for you since your husband died?" is to determine the risk for pathologic grief and the need for grief therapy. The patient is experiencing symptoms of insomnia and significant weight loss following her husband's death, which could indicate complicated or pathologic grief. By asking this open-ended question, the healthcare provider can gain insight into the patient's emotional well-being, coping mechanisms, and overall adjustment to the loss. The response can help assess whether the patient might benefit from additional support or interventions, such as grief therapy, to help her navigate through the grieving process in a healthy manner. It is essential to identify and address any potential complications related to grieving to provide appropriate care and support to the patient.
Immediately after electroconvulsive therapy, in which position should a nurse place the client?
- A. On his or her side to prevent aspiration.
- B. In semi-Fowlers position to promote oxygenation
- C. In Trendelenburg’s position to promote blood flow to vital organs
- D. In prone position to prevent airway blockage
Correct Answer: A
Rationale: Immediately after ECT, the patient may still be recovering from the effects of muscle relaxants and the seizure. Positioning the client on their side helps prevent aspiration in case of vomiting and maintains an open airwa
When differentiating between bereavement symptoms and depression, the nurse will base the formulation on knowledge that in bereavement:
- A. Suicide thoughts are common.
- B. Symptoms remit and exacerbate.
- C. Guilt feelings are overwhelming.
- D. Psychomotor retardation is obvious.
Correct Answer: B
Rationale: Bereavement involves waves of emotional pain, often triggered by reminders of the loss, whereas depression typically causes persistent symptoms such as guilt or hopelessness.
An elderly patient brings a bag of medications to the clinic. The nurse finds a bottle labeled Ativan and one labeled lorazepam, both of which are to be taken BID. There are also bottles labeled hydrochlorothiazide, Inderal, and rofecoxib, each to be taken once daily. Which conclusion is accurate?
- A. Rofecoxib should not be taken with Ativan
- B. Lorazepam and Ativan are the same drug, so the dose is excessive.
- C. Lorazepam interferes with the action of Inderal.
- D. The patient should not self-administer medication.
Correct Answer: B
Rationale: Ativan and lorazepam are the same drug, so the patient is taking an excessive dose of lorazepam. This requires intervention by the nurse to prevent harm.