Nokea
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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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
According to Piaget, which of the following would the nurse consider normal when assessing a 6-year-old?
- A. Playing with an imaginary friend
- B. Talking about their best friend
- C. Enjoying putting puzzles together
- D. Knowing it’s wrong to tell a lie
Correct Answer: C
Rationale:
At 6 years old, children are typically in the concrete operational stage of development, characterized by logical thinking and enjoyment of problem-solving activities like puzzles.
Which statement best explains how a mother of several children should prepare to help them cope with the loss of a dear aunt?
- A. Children are resilient and simply need love as they grieve.
- B. People regardless of age or gender experience stages of grief.
- C. Each child will grieve in a unique way and on their own timetable
- D. .Extreme reactions are more commonly observed in the young griever.
Correct Answer: C
Rationale: Each child will grieve in a unique way and on their own timetable. It is essential for the mother to acknowledge and understand that each of her children will process the loss of their dear aunt differently. Some children might show their emotions openly and seek comfort, while others might prefer to process their feelings more privately. By recognizing and respecting these individual differences, the mother can provide the necessary support tailored to each child's specific needs. This approach helps create a supportive environment where each child feels understood and cared for as they navigate their grief journey.
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.
In the ECT treatment preparation period the morning of treatment, the nurse should:
- A. Assess the patient’s cognitive function.
- B. Have the patient exercise for 10 minutes.
- C. Ensure that the patient produces a urine sample.
- D. Allow the patient to eat a heavy meal if they are hungry.
Correct Answer: A
Rationale: The correct action during the ECT treatment preparation period the morning of treatment is to adequately hydrate the patient. Ensuring that the patient is properly hydrated before the procedure is crucial for their safety and well-being. Hydration helps optimize the effects of the treatment and can support the patient's recovery post-treatment. It is important to maintain the patient's fluid balance as ECT can sometimes cause side effects such as nausea, headache, and muscle aches, which can be worsened if the patient is not adequately hydrated. Additionally, hydration can help prevent complications such as dehydration or electrolyte imbalances during and after the ECT procedure.