An elderly patient brings a bag of medications to the clinic. The nurse finds a bottle labeled Ativan and one labeled lorazepam, both of which are to be taken BID. There are also bottles labeled hydrochlorothiazide, Inderal, and rofecoxib, each to be taken once daily. Which conclusion is accurate?

Correct Answer: B

Rationale: Ativan and lorazepam are the same drug, so the patient is taking an excessive dose of lorazepam. This requires intervention by the nurse to prevent harm.

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.

Correct Answer: A

Rationale: The wife's statement, "It can't be," indicates that she is experiencing shock and disbelief at the news of her husband's death. This response is common when individuals are faced with a sudden and unexpected loss. The wife's blank stare and statement suggest that she is struggling to accept the reality of the situation, which aligns with the symptoms of shock and disbelief.

Correct Answer: B

Rationale: Ativan and lorazepam are the same drug, so the patient is taking an excessive dose of lorazepam. This requires intervention by the nurse to prevent harm.

Correct Answer: C

Rationale: At 6 years old, children are typically in the concrete operational stage of development, characterized by logical thinking and enjoyment of problem-solving activities like puzzles.

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.

Correct Answer: B

Rationale: Providing information about grief is an important intervention for individuals experiencing acute grief. It helps the patient understand their emotional reactions and the natural process of grieving, reducing feelings of isolation or confusion.

Correct Answer: C

Rationale: When caring for a patient who has received multiple electroconvulsive therapy (ECT) treatments and has more scheduled, the most critical milieu factor that needs attention is safety. ECT is a medical procedure that involves inducing seizures through electrical stimulation, and patients may be at risk of physical harm during or after the treatments. The nurse should prioritize ensuring the patient's safety during and after the ECT sessions, including monitoring for any adverse effects, providing support, and taking necessary precautions to prevent accidents. Safety measures, such as fall prevention protocols and close observation, are essential in the care of patients undergoing ECT to ensure their well-being. Therefore, safety is the milieu factor that requires the most attention in this situation.

Correct Answer: C

Rationale: Identifying triggers for hallucinations is a key step in managing symptoms effectively