The LPN/LVN is caring for an older adult who was admitted to the long-term care facility 2 months previously. Three weeks ago his son was killed in a car accident. The patient I been staying in his room and not attending meals or activities. What would be the highest priority patient problem for this patient?

Grieving related to loss of son

Social isolation related to depression

Ineffective coping related to the number of recent losses

Hopelessness related to relocation to a nursing home

Answer and Explanation

The Correct Answer is A

A. Grieving related to loss of son: The recent loss of his son is a significant and primary concern, leading to social withdrawal and other behaviours.
B. Social isolation related to depression: While social isolation is a concern, it stems from the primary issue of grieving.
C. Ineffective coping related to the number of recent losses: Ineffective coping is important but addressing the grieving process is more immediate and central.
D. Hopelessness related to relocation to a nursing home: Hopelessness due to relocation may contribute but is not the immediate primary issue in light of the recent death.

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Correct Answer is B

Explanation

A. Site of the lesions: The site of the lesions is addressed by the "S" in some mnemonics, but in PQRST, it refers to severity.

B. Severity of the symptoms: In the PQRST mnemonic for pain assessment, "S" stands for severity, referring to how intense or bothersome the symptoms are.

C. Surface area of the lesions: Surface area is not typically included in the PQRST mnemonic but may be relevant for other assessments.

D. Symptomatology of the lesions: Symptomatology encompasses the overall symptoms but is not specifically what "S" represents in PQRST.

A. Anxiety related to uncertainty of the events of the test B. Deficient knowledge related to lack of information regarding the procedure C. Disturbed thought process related to confusion D. Disturbed thought process related to temporary memory loss

Correct Answer is A

Explanation

A. Anxiety related to uncertainty of the events of the test: Addressing the patient's anxiety and providing information about the procedure can help reduce fear and improve cooperation.
B. Deficient knowledge related to lack of information regarding the procedure: While providing information is important, the immediate emotional response (anxiety) takes priority as it can impact the patient's experience of the procedure.
C. Disturbed thought process related to confusion: While disturbed thought processes are relevant, they are not the primary concern pre-procedure.
D. Disturbed thought process related to temporary memory loss: Temporary memory loss can occur post-ECT, but addressing pre-procedure anxiety is a more immediate priority.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The home health nurse assessing skin lesions uses the PQRST mnemonic as a guide. What does the S in this guide indicate?

Correct Answer is B

Explanation

A patient is preparing to receive electroconvulsive therapy. The nurse caring for this patient identifies which patient problem as the highest priority?

Correct Answer is A

Explanation

The patient talks with his dead brother and arranges furniture so that his brother will have a place to sit. How should the nurse document this behavior?

A patient admitted for delirium demonstrates increased disorientation and agitation only during the evening and nighttime. What is the term applied to this type of delirium?

A patient developed a severe contact dermatitis of the hands, arms, and lower legs after spending an afternoon picking strawberries. The patient states that the itching is severe and cannot keep from scratching. Which instruction will be helpful in managing the pruritus?

The nurse reminds the 80-year-old patient that her respiratory system has decreased resistance to respiratory infections. For what is this patient at increased risk?

Which is important for the nurse to assess when inspecting the skin of a patient?

A home health nurse has a patient who is taking lithium. What should be included in the teaching plan?

A 60-year-old man was admitted for cholecystitis that resulted in a cholecystectomy. On his third day of hospitalization, he begins to sweat profusely, tremble, and has a blood pressure of 160/100. Based on these findings, what focused assessment should the nurse complete?

The nurse assesses an alcoholic patient carefully for signs of withdrawal. How soon after cessation of alcohol intake do withdrawal symptoms usually appear?