The nurse is caring for an older adult patient who has no history of violence but is agitated and appears ready to strike out at a staff member. The nurse would assess the patient for which of the following?

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Question 1 of 5

The nurse is caring for an older adult patient who has no history of violence but is agitated and appears ready to strike out at a staff member. The nurse would assess the patient for which of the following?

Correct Answer: D

Rationale: The correct answer is D: Sensory losses. In this scenario, the older adult patient's agitation and readiness to strike out may be due to sensory losses such as hearing or vision impairment, leading to frustration and miscommunication. Assessing for sensory losses is crucial to understand the root cause of the patient's behavior and provide appropriate interventions. A: Panic disorder - This choice is incorrect as panic disorder typically presents with sudden and intense episodes of fear or anxiety, not necessarily leading to physical aggression. B: Epilepsy - This choice is incorrect as epilepsy is a neurological disorder characterized by seizures, not typically associated with sudden aggression. C: Bipolar disorder - This choice is incorrect as bipolar disorder involves distinct episodes of mania and depression, which may not directly cause the patient's behavior in this situation.

Question 2 of 5

The nurse is working with the family of a patient with obsessive-compulsive disorder (OCD). Which concept should the nurse incorporate in the teaching plan?

Correct Answer: C

Rationale: The correct answer is C because OCD symptoms typically worsen with stress due to increased anxiety triggering obsessions and compulsions. This understanding is crucial for the family to help manage the condition effectively. Option A is incorrect because thoughts in OCD are intrusive and involuntary. Option B is incorrect as immediate attention may reinforce the symptoms. Option D is incorrect as OCD can respond well to treatment approaches like therapy and medication.

Question 3 of 5

A nurse is giving a presentation to a community group about sleep and its relationship to health. In explaining the relationship between REM sleep and body temperature, which statement by the nurse would be most appropriate?

Correct Answer: C

Rationale: The correct answer is C. REM sleep and body temperature cycles are inversely related. During REM sleep, our body temperature decreases, which is essential for the body to conserve energy and maintain a state of relaxation. This decrease in body temperature during REM sleep helps promote the restoration and rejuvenation of the body. It is crucial for the nurse to convey this information accurately to the community group to emphasize the importance of quality sleep for overall health. Choice A is incorrect because there is indeed an observable relationship between REM sleep and body temperature. Choice B is incorrect as higher levels of REM sleep are associated with lower body temperatures, not higher. Choice D is incorrect as the experience of REM sleep is not directly proportional to a rise in body temperature; instead, it is inversely related.

Question 4 of 5

The nurse is assessing a client who has a history of heavy drinking and who lost his wife to cancer during the previous year. He reports that he isn't getting as much sleep as he used to when he was younger. Which question would be most appropriate to ask the client to determine if the change in his sleep pattern is related to normal aging or depression?

Correct Answer: B

Rationale: The correct answer is B: "Is it hard for you to fall asleep or remain asleep during the night?" This question is most appropriate because it directly addresses the client's current sleep issues and can provide insights into whether he is experiencing symptoms of depression, such as insomnia or disrupted sleep patterns. By focusing on the client's sleep difficulties, the nurse can better assess if the changes are related to normal aging or if they are indicative of an underlying mood disorder like depression. Choice A is incorrect as it does not address the client's current sleep problems. Choice C is not relevant to the client's sleep patterns and focuses on alcohol consumption. Choice D is also irrelevant to the client's sleep issues and does not directly assess potential depressive symptoms.

Question 5 of 5

A nurse is interviewing a client who is a survivor of abuse. The client is telling the nurse about how the violence occurred. Which statement would the nurse interpret as reflecting phase 3 of the cycle of violence?

Correct Answer: D

Rationale: Step 1: Phase 3 of the cycle of violence is the reconciliation or "honeymoon" phase where the abuser shows remorse, apologizes, and promises to change. Step 2: In choice D, the abuser apologizes and promises not to hit again, indicating the reconciliation phase. Step 3: Choices A, B, and C reflect earlier phases of the cycle - tension building (choice B) and the explosion phase (choices A and C). Step 4: In summary, choice D is correct as it aligns with the characteristics of phase 3, while choices A, B, and C represent earlier stages of the cycle of violence.

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