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Which statement would the nurse use to describe the primary purpose of boundaries?
- A. Boundaries define responsibilities and duties to one’s self in relation to others.
- B. Boundaries determine objectives of the various working stage of the relationship.
- C. Boundaries differentiate the assumed roles of both the nurse and of the patient.
- D. Boundaries prevent undesired material from emerging during the interaction.
Correct Answer: A
Rationale: Boundaries define responsibilities and duties to one’s self in relation to others. Setting boundaries is essential in establishing a safe and professional therapeutic relationship between a nurse and a patient. These boundaries help to create a clear understanding of each person's roles and responsibilities within the relationship. Boundaries also help protect both the nurse and the patient from potential harm, maintain professionalism, and ensure effective communication and focus on the therapeutic goals. By defining these boundaries, the nurse can better maintain appropriate relationships with patients and avoid conflicts of interest or ethical dilemmas.
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Which patient would the nurse determine to be at highest risk for dysfunctional grief? The patient:
- A. Whose 16-year-old daughter was raped and killed while going on an errand for the patient
- B. Whose 86-year-old mother, with whom she has shared her home, died after a long illness.
- C. Who attended a support group and had been assisted by hospice to care for her terminally ill husband
- D. Who attended a bereavement group, where she learned to express feelings after the deaths of her twin daughters
Correct Answer: A
Rationale: The patient whose 16-year-old daughter was raped and killed while going on an errand for the patient would be determined to be at highest risk for dysfunctional grief. This traumatic event involves sudden and violent loss of a child, which can lead to complicated or dysfunctional grief reactions. The circumstances of the death, involving violence, unexpectedness, and the close relationship with the deceased, can significantly impact the grieving process. The patient may struggle with intense emotions, guilt, anger, and unresolved trauma, making them more vulnerable to experiencing dysfunctional grief. It is essential for healthcare professionals to provide appropriate support and interventions to help the patient navigate through this complex grieving process.
A patient is experiencing distress with midlife transition. Which statement provides support that the patient is successfully managing this stressor?
- A. “I won’t give up on my dream to be rich.”
- B. “I wasn’t being realistic when I set being rich as my life’s goal.”
- C. “I’ll never be rich, but I can save enough to live comfortably.”
- D. “Being rich doesn’t necessarily make a person happy.”
Correct Answer: C
Rationale: Successfully managing midlife transitions involves finding realistic and satisfying alternatives to earlier, unmet goals, demonstrating emotional growth and adaptability.
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
A nurse, leading an inpatient group dealing with women’s issues, identifies a patient who is assuming the role of aggressor. Which behavior characterizes this role?
- A. Mediating conflicts and disagreements
- B. Criticizing the contributions of others
- C. Seeking a position between contending sides
- D. Remaining quiet and refraining from participating in group discussions
Correct Answer: B
Rationale: In a group setting, a patient assuming the role of aggressor typically exhibits behaviors such as criticizing the contributions of others, being hostile, confrontational, and attempting to assert dominance. This behavior can create a negative and hostile environment in the group, undermining the therapeutic process. It is important for the nurse to recognize and address this behavior in order to promote a safe and supportive atmosphere for all group members to participate and benefit from the sessions.
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.