Nokea
A home health nurse is making a home visit to a psychiatric patient who was recently discharged from a mental health unit. During the visit, the nurse plans on clarifying when she will return for the next home visit. During which stage would the nurse discuss the next home visit with the patient?
- A. Closure stage
- B. Service implementation
- C. Greeting stage
- D. Focus establishment
Correct Answer: A
Rationale: Discussing the next visit occurs during the closure stage, as it involves wrapping up the current interaction and planning future contact. Service implementation involves care delivery, greeting establishes rapport, and focus establishment sets the session?s purpose.
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The nurse is determining the success of a patient?s plan of care by evaluating outcome indicators. The nurse understands that these indicators are usually determined initially at which time?
- A. On the day of discharge
- B. During the assessment process
- C. At the initial interview
- D. With goal-setting process
Correct Answer: D
Rationale: Outcome indicators are specific, measurable criteria established during the goal-setting process in the nursing plan of care. This occurs after assessment and diagnosis, aligning interventions with desired outcomes. Discharge, assessment, and initial interviews precede or inform goal-setting.
During assessment, the nurse asks a patient to explain what the following means: 'A penny saved is a penny earned.' The nurse is assessing which of the following?
- A. Affect
- B. Attention
- C. Concentration
- D. Abstract reasoning
Correct Answer: D
Rationale: Interpreting proverbs like 'A penny saved is a penny earned' requires abstract reasoning, the ability to understand and analyze abstract concepts. Affect involves emotional expression, attention is focus, and concentration is sustained mental effort.
A nurse is assisting a patient in using simple relaxation techniques. Which of the following would the nurse do first?
- A. Have the patient assume a relaxed position.
- B. Advise the patient to let the sensations happen.
- C. Ensure a quiet, nondisrupting environment.
- D. Instruct the patient to take an initial slow, deep breath.
Correct Answer: C
Rationale: Ensuring a quiet, nondisrupting environment is the first step in relaxation techniques, as it creates optimal conditions for relaxation. Positioning, allowing sensations, and deep breathing follow to facilitate the process.
After assessing a patient, the nurse noted the following: he was tearful, he tried to kill himself before coming into the hospital, he had no immediate plan for another suicide attempt, he was unable to concentrate, and he reported having trouble sleeping and having little or no appetite. The nurse also noted that the patient?s appearance was unkempt, that he spoke in a low monotone, and that he was unable to establish and maintain eye contact. Based on this information, which nursing diagnoses would be the most appropriate?
- A. Ineffective Role Performance
- B. Risk for Infection
- C. Risk for Suicide
- D. Risk for Self-Mutilation
Correct Answer: C
Rationale: The patient?s recent suicide attempt, tearfulness, and depressive symptoms (poor concentration, sleep issues, low appetite, unkempt appearance) indicate a high risk for suicide, making 'Risk for Suicide' the most appropriate diagnosis. Ineffective Role Performance is less immediate, and there?s no evidence for infection or self-mutilation risk.
A patient was brought to the emergency department for an injury he received while working as a migrant worker. It soon becomes evident that the patient cannot speak English. A nurse on duty offers to find an interpreter so the patient can communicate with the medical staff. The nurse?s offer is an example of which type of nursing intervention?
- A. Milieu therapy
- B. Conflict resolution
- C. Cultural brokering
- D. Structured interaction
Correct Answer: C
Rationale: Cultural brokering involves facilitating communication and understanding between individuals of different cultural or linguistic backgrounds, such as securing an interpreter for a non-English-speaking patient. Milieu therapy manages the therapeutic environment, conflict resolution addresses disputes, and structured interaction is less specific.