Ms. Maria Salvacion says that she is the incarnation of the holy Virgin Mary. She said that she is the child of the covenant that would save this world from the evil forces of Satan. One morning, while caring for her, she stood in front of you and said ¢â‚¬Å“Bow down before me! I am the holy mother of Christ! I am the blessed Virgin Mary!¢â‚¬ The best response by the Nurse is:

Correct Answer: B

Rationale: The best response by the nurse in this scenario is option B) "So, You are the Virgin Mary?" This response demonstrates therapeutic communication by acknowledging the patient's statement without challenging or agreeing with delusional beliefs. It allows the nurse to maintain a non-judgmental stance and opens the opportunity for further assessment of the patient's mental status. Option A is incorrect because it encourages the patient's delusion by asking for more information about her belief. Option C is inappropriate as it directly challenges the patient's belief in a confrontational manner, which can escalate the situation and harm the nurse-patient relationship. Option D is also incorrect as it does not address the patient's statement and fails to provide appropriate therapeutic communication. In an educational context, it is crucial for healthcare professionals to develop effective communication skills to navigate challenging situations like this. Understanding how to respond to delusional beliefs with empathy and respect is vital in maintaining a therapeutic relationship and ensuring the safety and well-being of the patient.

Correct Answer: B

Rationale: The correct answer is B) Maturational crisis. A maturational crisis is a type of crisis that arises when an individual reaches a new developmental stage in life and must learn new skills and adapt to new challenges. In Ms. ANA's case, losing her boyfriend in a car accident has triggered a crisis that is related to her personal growth and development. Option A) Developmental crisis typically refers to crises that occur as a result of normal life transitions, such as adolescence or retirement. Ms. ANA's situation is not a typical developmental crisis but rather a more specific crisis related to a significant loss. Option C) Situational crisis involves a specific event or situation that causes an individual distress. While losing her boyfriend is a situational event, the specific nature of the crisis is more aligned with a maturational crisis due to the impact on Ms. ANA's personal growth. Option D) Social crisis involves a breakdown in social structures or systems within a community. Ms. ANA's crisis is more individualized and focused on her personal response to a traumatic event, rather than a societal issue. Educationally, understanding different types of crises is important for healthcare professionals, including nurses, as it helps them assess and provide appropriate support to individuals experiencing crisis situations. Recognizing the specific type of crisis can guide interventions and support strategies tailored to the individual's needs during times of distress.

Correct Answer: A

Rationale: In alcoholic patients, the vitamin deficiency that can lead to psychoses is thiamine, also known as Vitamin B1. Thiamine plays a crucial role in brain function and a deficiency can result in serious neurological complications such as Wernicke-Korsakoff syndrome, characterized by confusion, ataxia, and memory issues. Alcohol interferes with thiamine absorption and utilization, making alcoholic individuals particularly prone to deficiency. Option A (Thiamine) is the correct answer as explained above, addressing the specific vitamin deficiency seen in alcoholic patients that can lead to psychoses. Option B (Vitamin C) is incorrect because while Vitamin C deficiency can lead to scurvy, a condition characterized by weakness and bleeding gums, it is not associated with psychoses. Option C (Niacin) is incorrect as niacin deficiency can lead to pellagra, a condition characterized by dermatitis, diarrhea, and dementia, but it is not the primary vitamin deficiency leading to psychoses in alcoholic patients. Option D (Vitamin A) is incorrect as Vitamin A deficiency is associated with vision problems and immune system issues, but not psychoses. Understanding the specific vitamin deficiencies related to alcoholism is crucial for nurses to provide appropriate care and prevent serious complications in alcoholic patients. Education on nutrition and the impact of alcohol on vitamin absorption is essential for nurses to recognize and address these deficiencies in their practice.

Correct Answer: A

Rationale: The correct answer is A) Stimulation in the brain to increase brain conduction and counteract depression. Electroconvulsive therapy (ECT) is a treatment option for severe depression that involves delivering electrical currents to the brain to induce a controlled seizure. This process is believed to increase brain activity and promote the release of neurotransmitters like serotonin and norepinephrine, which are essential for mood regulation. ECT is not about creating brain damage or charging neurons; it aims to stimulate brain function and improve symptoms of depression. Option B) Mainly Biologic, increasing the norepinephrine and serotonin level, is incorrect because ECT works through electrical stimulation rather than directly increasing neurotransmitter levels. Option C) Creates a temporary brain damage that will increase blood flow to the brain is incorrect as ECT does not aim to cause brain damage; it is a carefully monitored procedure with minimal side effects. Option D) Involves the conduction of electrical current to the brain to charge the neurons and combat depression is incorrect because the goal of ECT is not to "charge" neurons but to modulate brain activity to alleviate depressive symptoms. In an educational context, understanding the mechanism of action of ECT is crucial for healthcare professionals working with clients with severe depression. It is important to differentiate between the myths and facts surrounding ECT to provide accurate information and support to clients considering this treatment option.

Correct Answer: A

Rationale: The correct answer is option A) “Don’t say you are worthless, you are not a worthless person.” This response is the best because it directly addresses the client's statement of feeling worthless by providing reassurance and challenging the negative self-perception. This approach can help the client feel supported, validated, and may prevent further escalation of negative thoughts. Option B) “We are going to help you with your feelings” is not as effective as it does not directly address the client's statement about feeling worthless. It is important to acknowledge and challenge the negative self-talk rather than just offering general assistance. Option C) “What makes you feel you’re worthless?” while showing empathy, does not challenge the negative statement directly. It is important to provide immediate support and positive reinforcement in such situations. Option D) “What you say is not true” is dismissive and can invalidate the client's feelings. It is crucial to approach the situation with empathy and understanding rather than outright denial. In an educational context, this question highlights the importance of therapeutic communication skills in nursing practice, especially when dealing with clients experiencing emotional distress or expressing negative thoughts. Nurses must be equipped to respond empathetically, provide support, and challenge negative self-perceptions to promote mental health and well-being in their clients.