Your patient sometimes forgets to eat. In which part of the nursing care plan would the nurse expect to find this statement: “Offer snacks and finger foods frequently”?
Intervention
Planning/Goals
Assessment
Diagnosis
The Correct Answer is A
Choice A reason: Interventions, like offering snacks, address identified problems (e.g., forgetting to eat) to meet nutritional needs. This action targets physiological deficits, potentially linked to cognitive impairments from low acetylcholine in dementia, ensuring adequate caloric intake to support brain function and overall health in the care plan.
Choice B reason: Planning/goals outline desired outcomes, not specific actions. Forgetting to eat, possibly due to frontal lobe dysfunction, requires goals like “maintain adequate nutrition.” Interventions, not goals, specify actions like offering snacks, making this section incorrect for the statement’s placement in the care plan.
Choice C reason: Assessment involves data collection, like observing eating patterns, not actions like offering snacks. Forgetting to eat may reflect cognitive deficits, but assessment identifies the problem, not solutions. This section precedes interventions, making it an incorrect location for the described statement.
Choice D reason: Diagnosis identifies problems, like “impaired nutrition” due to cognitive deficits, not specific actions. Offering snacks is an intervention to address the diagnosis, not the diagnosis itself. This section is incorrect for the statement, which belongs in the intervention phase of the care plan.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Muscarinic receptor blockers inhibit parasympathetic activity, reducing salivary gland secretion via acetylcholine pathways. This causes dry mouth, as muscarinic receptors in salivary glands are blocked, decreasing saliva production. This anticholinergic effect is common in drugs like benztropine, requiring assessment to manage discomfort and prevent oral health issues.
Choice B reason: Orthostatic hypotension is linked to alpha-1 adrenergic blockade, not muscarinic receptors. Muscarinic blockers affect cholinergic pathways, not vascular tone regulated by norepinephrine. While autonomic effects occur, hypotension is not a primary consequence, making this side effect unrelated to muscarinic receptor antagonism.
Choice C reason: Pseudoparkinsonism results from dopamine receptor blockade, common in antipsychotics, not muscarinic blockers. Muscarinic receptors regulate parasympathetic functions like salivation, not motor control. Blocking muscarinic receptors may alleviate parkinsonism by balancing cholinergic-dopaminergic activity, making this an incorrect side effect for assessment.
Choice D reason: Gynecomastia is associated with hormonal imbalances or dopamine blockade, not muscarinic receptors. Muscarinic blockers affect cholinergic systems, not prolactin or estrogen pathways. This side effect is unrelated to muscarinic antagonism, which primarily causes anticholinergic effects like dry mouth, not endocrine changes.
Correct Answer is D
Explanation
Choice A reason: A trusting relationship is the goal of therapeutic alliances, not countertransference. It reflects effective communication, calming amygdala-driven distress in suicidal patients. This is a normal outcome, not an emotional overreaction, making it an incorrect indicator of countertransference in psychiatric care.
Choice B reason: The patient comparing the nurse to parents suggests transference, not countertransference. Transference involves patient projections, often tied to past emotional patterns, not nurse emotions. This is unrelated to the nurse’s feelings, making it an incorrect choice for countertransference concerns.
Choice C reason: Realistic patient reactions indicate a healthy therapeutic dynamic, not countertransference. Appropriate responses align with stabilizing neurobiological states, like serotonin balance in depression. This reflects effective care, not nurse emotional overinvolvement, making it an incorrect indicator of countertransference in this context.
Choice D reason: Extreme happiness tied to the patient’s mood improvement suggests countertransference, where the nurse’s emotions, possibly influenced by mirror neuron activation, overly align with the patient’s state. This indicates personal overinvolvement, risking bias in care for suicidal patients with serotonin imbalances, making it the correct choice.
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