A patient tells the nurse, "Air Force jets flying overhead are looking for me. They want to capture me." The patient has not previously verbalized this information. The nurse's initial interventions should
a. set firm limits on disruptive behaviors.
b. forcefully refute all perceptual distortions.
c. encourage complete description of delusions.
d. voice doubt about delusions without arguing.
D
A nurse cannot agree with a delusion, but arguing is counterproductive, because it might cause the patient to cling to the idea. Voicing doubt and stating one's own perception of reality is therapeutic. Encouraging discussion of the delusion reinforces it. Because the behavior described is not disruptive, this principle is not relevant.
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An ED nurse is assessing an adult woman for a suspected MI. When planning the assessment, the nurse should be cognizant of what signs and symptoms of MI that are particularly common in female patients? Select all that apply
A) Shortness of breath B) Chest pain C) Anxiety D) Numbness E) Weakness
A pathologist is examining histological (tissue) samples from a client with an autoimmune disease. Which of the following characteristics of muscle samples would signal the pathologist that the samples are cardiac rather than skeletal muscle?
A) The cell samples lack intercalated disks. B) The muscle cells have small and a few mitochondria. C) The cells have a poorly defined sarcoplasmic reticulum. D) The muscles are striated and composed of sarcomeres.
An older adult patient with dementia is seen at the clinic for a physical examination. The son tells the nurse, "I don't know how much more of this I can do
There is so much work involved in just getting my dad out of bed in the morning, and I can't communicate with him. I'm just so tired." The nurse recognizes that the son is most likely experiencing: a. Symptoms of depression b. Caregiver role strain c. Serious frustration d. Resentment over being the only care provider
To plan effectively for an individual who is in crisis, the nurse must have an understand-ing of:
a. Methods to establish rapport b. Family counseling techniques c. The meaning of the crisis event to the individual d. Posttraumatic stress disorder treatment modalities