A disheveled patient with severe depression and psychomotor retardation has not showered for several days. What will the nurse do?
Avoid forcing the issue in order to minimize stress
Calmly tell the patient, "You must bathe daily"
Bring up the issue at the community meeting
Firmly and neutrally assist the patient with showering
The Correct Answer is D
Choice A reason: Avoiding the issue allows the patient's hygiene to deteriorate further, which can lead to skin breakdown or infections. While minimizing stress is important, neglecting physical care in a patient with psychomotor retardation is a failure to meet basic physiological needs that the patient currently cannot meet.
Choice B reason: Simply telling a patient with severe depression and psychomotor retardation that they "must" bathe is often ineffective. These patients frequently lack the physical energy or cognitive drive to initiate complex tasks. Such demands may increase feelings of inadequacy or worthlessness without providing the necessary support.
Choice C reason: Bringing a personal hygiene issue to a community meeting is a violation of the patient's privacy and dignity. It can cause significant embarrassment and shame, potentially worsening the patient's depressive symptoms and damaging the therapeutic alliance between the nurse and the patient.
Choice D reason: Patients with severe psychomotor retardation require direct assistance because they lack the volition to perform ADLs. A firm, neutral, and supportive approach provides the necessary structure and physical help to maintain hygiene and self-respect without being punitive or overly demanding, ensuring the patient's safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Primary crisis intervention focuses on health promotion and reducing the incidence of crisis by teaching coping skills or altering the environment before a crisis occurs. Since the plane crash (the crisis event) has already happened, this intervention is no longer in the primary stage.
Choice B reason: Secondary crisis intervention involves acute treatment during an actual crisis to prevent prolonged suffering. This usually occurs immediately following the event. Since the patient has already returned to work and is receiving monthly follow-up care, the focus has shifted beyond the acute phase.
Choice C reason: Tertiary crisis intervention, also known as postvention, provides support for those who have experienced a severe crisis and are now in the recovery phase. Meeting once a month to provide support and facilitate optimal levels of functioning after the event is a hallmark of tertiary prevention.
Choice D reason: Critical incident stress debriefing is a specific, structured group intervention that typically occurs within 24 to 72 hours of a traumatic event. Monthly individual support sessions do not meet the criteria for this highly specialized, short-term, one-time stabilization technique used for groups.
Correct Answer is D
Explanation
Choice A reason: Level of motor activity can vary widely in both delirium (hyperactive or hypoactive subtypes) and dementia. While psychomotor agitation is common in delirium, it is not a definitive diagnostic differentiator, as elderly patients with advanced dementia or depression can also exhibit significant changes in their activity levels.
Choice B reason: Spasticity or flaccidity are physical neurological signs typically associated with upper or lower motor neuron lesions, such as those following a stroke or spinal cord injury. While they indicate physical brain damage, they do not help distinguish the cognitive etiologies of acute confusion versus chronic neurocognitive decline.
Choice C reason: Preoccupation with somatic (physical) symptoms is more characteristic of somatic symptom disorders or health anxiety. While some elderly patients may focus on physical complaints during a depressive episode, this information does not provide the temporal clarity needed to differentiate the rapid onset of delirium from chronic dementia.
Choice D reason: The hallmark of delirium is its acute onset (developing over hours or days) and fluctuating course. In contrast, dementia involves a slow, progressive decline over months or years. Determining the timeline of the confusion is the most critical step
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.