Nokea
A 34-year-old male with catatonic schizophrenia has been mute and motionless for several days. Which nursing intervention would be an initial priority?
- A. Orienting the patient to the unit.
- B. Reinforcing reality with the patient.
- C. Establishing a nonthreatening relationship.
- D. Administer prescribed medications or intervention
Correct Answer: C
Rationale: Building trust and rapport is essential when working with patients in a catatonic or withdrawn state.
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A 76-year-old is regressed, indifferent, and responds to others only when they initiate an interaction. What form of group therapy would be most useful to promote resocialization?
- A. Remotivation
- B. Activity group
- C. Psychotherapy
- D. Reminiscence (life review)
Correct Answer: A
Rationale: Remotivation therapy focuses on stimulating engagement and interaction in patients who are socially withdrawn or have limited emotional responses. It helps the individual reconnect with their environment and others.
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.
A friend says to a nurse, “I am not going to get vaccines for my baby. I hear that vaccines cause autism.” The nurse’s best reply is:
- A. The exact cause of autism is not really known
- B. It’s believed that autism is really a result of birth trauma
- C. There is no conclusive evidence to connect autism to vaccinations.
- D. Please tell me more about where you got that information about autism?
Correct Answer: C
Rationale: This response provides factual, evidence-based information to address the common misconception linking vaccines to autism. It is clear and reassuring for the parent.
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.
An outcome for a patient experiencing anticipatory grieving for a spouse diagnosed with
terminal cancer would be that the patient will:
- A. Continue to be emotionally involved with the dying spouse
- B. Develop protective mental mechanisms to allay the pain of spousal loss
- C. Not voice threats of physical violence that is either self or others directed
- D. Agree to stay at home and care for the spouse with appropriate assistance
Correct Answer: D
Rationale: Anticipatory grieving involves preparing emotionally for the upcoming loss. The patient may begin to focus on caregiving and emotional preparation. Agreeing to care for the spouse with assistance reflects an adaptive coping mechanism during this period.