Nokea
A 19-year-old patient with undifferentiated schizophrenia is acutely psychotic. The nurse assesses the primary deficit as:
- A. Social isolation
- B. Disturbed thinking
- C. Altered mood states
- D. Poor impulse control
Correct Answer: B
Rationale: Acute psychosis primarily affects thought processes, evidenced by delusions or disorganized thinking.
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A new nurse asks the mentor, “How can I be sure I’m developing a therapeutic environment for my unit?” The mentor uses as a basis for the response the fact that a therapeutic milieu is characterized by:
- A. Rigid adherence to timelines and unit routine
- B. Relaxation of boundaries when doing so is accepted by all
- C. Working with a member to help improve their communication skill
- D. The focus of the staff is directed to the most critically disturbed patients
Correct Answer: D
Rationale: A therapeutic milieu is characterized by focusing on the needs and goals of the patients. By establishing specific patient-centered goals that are agreed upon mutually by the patient and the staff, it ensures that the care provided is individualized and tailored to the patient's needs. This approach fosters a collaborative and empowering environment where the patient feels heard and supported in their recovery journey. It also promotes a sense of ownership and accountability for both the patient and the staff in working towards these goals together. In contrast, rigid adherence to timelines and unit routine (option A) may not always take into account the unique needs of each patient, and relaxation of boundaries (option B) can potentially compromise the therapeutic process by blurring professional boundaries. Therefore, establishing patient-centered goals is a key component of creating a therapeutic environment on a nursing unit.
Which nursing diagnosis is appropriate for a patient who insists on being called "Your Highness" and demonstrates loosely associated thoughts?
- A. Risk for violence
- B. Defensive coping
- C. Impaired memory
- D. Disturbed thought processes
Correct Answer: D
Rationale: nsisting on being called "Your Highness" and demonstrating loose associations suggests a disturbance in thought processing typical of schizophrenia.
Which response is appropriate when a patient’s mother expresses guilt over causing my child to be schizophrenic?
- A. I can see how you would be upset over this turn of events
- B. New findings suggest this disorder is biological in nature.
- C. Don’t be so hard on yourself; your daughter needs you to be strong
- D. It’s difficult to see what produces stress for the child at the time it’s occurring.
Correct Answer: B
Rationale: Schizophrenia is primarily linked to biological factors, including genetic predispositions, neurochemical imbalances, and brain structure abnormalities. This response helps dispel guilt and provides reassurance to the mother.
A nurse administers ordered preoperative glycopyrrolate (Robinul) 30 minutes prior to a client’s electroconvulsive therapy (ECT) procedure. What is the rationale for administering this medication?
- A. Robinul decreases anxiety during the ECT procedure.
- B. Robinul induces an unconscious state to prevent pain during the ECT procedure
- C. Robinul prevents severe muscle contractions during the ECT procedure.
- D. Robinul decreases secretions to prevent aspiration during the ECT procedure.
Correct Answer: D
Rationale: Glycopyrrolate is an anticholinergic that reduces salivation and other secretions, which helps to prevent aspiration during ECT, where muscle relaxants are used.
A novice mental health nurse shares that, “I’ll never get used to playing cards or other games with patients. It seems like a poor use of scarce nursing time.” The best response for the nurse’s mentor would be:
- A. “Perhaps you’ll want to rethink your transfer to this unit if you’re really uncomfortable.”
- B. “Your comments make a point about scarce resources. I’ll ask the treatment team to review our position on activities.”
- C. “Activity co-leadership puts us in a position to help patients develop social skills and support them as they take small risks.”
- D. “Managed care has cost us activities therapists. Activities are
Correct Answer: C
Rationale: The best response for the nurse’s mentor would be to highlight the importance of activities in mental health nursing. Participating in activities such as playing cards or games with patients is not just about passing time, but it also serves a therapeutic purpose. Engaging in activities helps patients to develop social skills, build relationships, and take small risks in a safe environment. As mental health nurses, it is crucial to understand that these activities are not a waste of time but rather an essential part of the therapeutic process. By participating in activities with patients, nurses can actively support their mental well-being and contribute to their overall treatment and recovery.