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: Abruptly stopping fluoxetine, an SSRI, disrupts serotonin levels, causing discontinuation syndrome with symptoms like dizziness and irritability due to rapid neurotransmitter imbalance in the brain. Gradual tapering stabilizes serotonin, preventing withdrawal, making this critical teaching for safe medication management in anxiety treatment.
Choice B reason: Constipation is not a common side effect of fluoxetine, which primarily causes nausea or diarrhea via serotonin modulation. Anticholinergic drugs, not SSRIs, typically cause constipation. This teaching is inaccurate, as fluoxetine’s side effect profile does not emphasize gastrointestinal slowing, making it incorrect.
Choice C reason: Fluoxetine takes 4-8 weeks, not months, to reach efficacy by increasing serotonin in the prefrontal cortex and amygdala. Overstating the timeline discourages adherence, as patients expect faster relief from anxiety symptoms, making this teaching point scientifically inaccurate and misleading.
Choice D reason: Fluoxetine is not addictive, as it lacks the reinforcing GABA effects of benzodiazepines. It modulates serotonin for anxiety without dependence risk. This teaching is incorrect, as it misrepresents fluoxetine’s pharmacological profile, potentially causing unnecessary fear about its safe use in treatment.
Correct Answer is A
Explanation
Choice A reason: Nurses must adhere to professional standards, ensuring safe care despite substandard policies. Restraint use, for example, must minimize harm and respect patient dignity, regardless of policy. This aligns with ethical principles and evidence-based practices for managing agitation linked to neurotransmitter imbalances, upholding nurse accountability.
Choice B reason: Leaving the premises after informing a supervisor abandons patients, violating ethical duties. Professional standards require nurses to advocate for safe practices, like appropriate restraint use for dopamine-driven agitation, within the system. This option is impractical and neglects patient care responsibilities, making it incorrect.
Choice C reason: Agency policies do not override professional standards. Nurses are accountable to evidence-based practices, ensuring interventions like restraints for severe agitation are safe and ethical. Policies may guide but cannot excuse deviations from standards addressing neurobiological safety needs, making this option scientifically and ethically incorrect.
Choice D reason: Judicial interpretation varies, but nursing practice is guided by professional standards, not unpredictable legal outcomes. Standards ensure safe, ethical care, like minimizing restraint use for serotonin-related agitation, regardless of policy or judicial variability. This option is irrelevant to guiding daily nursing practice.
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