Nokea
A nurse documents: "Patient is mute despite repeated efforts to elicit speech. Makes no eye contact. Inattentive to staff. Gazes off to the side or looks upward rather than at speaker." Which nursing diagnosis should be considered?
- A. Defensive coping
- B. Decisional conflict
- C. Risk for other-directed violence
- D. Impaired verbal communication
Correct Answer: D
Rationale: The correct answer is D: Impaired verbal communication. The patient's inability to speak, make eye contact, and focus on the speaker indicates a communication issue. Impaired verbal communication relates to difficulty expressing thoughts, feelings, or needs. The patient's behavior aligns with this diagnosis as they are mute, inattentive, and not making eye contact. Defensive coping (A) involves protecting oneself from emotional pain. Decisional conflict (B) pertains to uncertainty about choices. Risk for other-directed violence (C) involves potential harm to others, which is not evident in the scenario. Thus, D is the most appropriate nursing diagnosis.
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The nurse is assessing a child's cognitive ability to think logically. The nurse asks the child to count backward from 10 to 0, and the child complies. What cognitive stage is this child in?
- A. sensorimotor
- B. formal operational
- C. concrete operational
- D. preoperational
Correct Answer: C
Rationale: The child counting backward from 10 to 0 demonstrates conservation of numbers and reversibility, characteristics of the concrete operational stage. In this stage, children can engage in logical thought processes, manipulate information mentally, and understand conservation. This ability is typically developed around ages 7 to 11.
A: Sensorimotor stage focuses on sensory experiences and object permanence, typically occurring from birth to age 2.
B: Formal operational stage involves abstract thinking and hypothetical reasoning, usually from age 12 and beyond.
D: Preoperational stage includes egocentrism and lack of conservation, typical for children aged 2 to 7.
Therefore, the child counting backward is in the concrete operational stage due to their ability to think logically and understand conservation.
Taylor, a psychiatric registered nurse, orients Regina, a patient with anorexia nervosa, to the room where she will be assigned during her stay. After getting Regina settled, the nurse informs Regina:
- A. I need to go through the belongings you have brought with you.
- B. You can use the scale in the back room when you need to.
- C. You will be eating five times a day here.
- D. The daily structure is based around your desire to eat.
Correct Answer: A
Rationale: The correct answer is A because as a psychiatric nurse, it is important to ensure the safety of the patient, especially those with anorexia nervosa who may have harmful items in their belongings. Going through the patient's belongings allows the nurse to assess and remove any potential risks. This action aligns with the duty of care and ensures the patient's well-being.
Choice B is incorrect because using a scale can trigger anxiety and reinforce unhealthy behaviors related to weight monitoring in patients with anorexia nervosa. Choice C is incorrect as stating a specific number of meals may not be suitable for every individual and could create unnecessary pressure on the patient. Choice D is incorrect because the structure of care should be based on evidence-based practices and clinical guidelines, not solely on the patient’s desire to eat.
When describing the relapse cycle to a group of families of clients experiencing co-occurring disorders, which of the following would the nurse identify as occurring first?
- A. Hospitalization
- B. Decompensation
- C. Stabilization
- D. Discharge
Correct Answer: B
Rationale: The correct answer is B: Decompensation. In the relapse cycle of co-occurring disorders, decompensation typically occurs first. Decompensation refers to a deterioration in mental health symptoms or functioning. This phase often precedes hospitalization, stabilization, and discharge. It signifies a worsening of symptoms and coping mechanisms, leading to a need for increased support and intervention. Hospitalization (choice A), stabilization (choice C), and discharge (choice D) usually occur after decompensation as steps in the treatment process to address the relapse.
The nurse has instructed a client with panic disorder about how to use the technique of positive self-talk. The nurse determines that the client has understood the instructions when the client verbalizes which statement to use during an impending panic attack?
- A. I am feeling very nervous right now.
- B. I can handle this anxiety; it will be over shortly.
- C. I am taking medication to eliminate these symptoms.
- D. Relax your muscles, relax your muscles.
Correct Answer: B
Rationale: The correct answer is B: "I can handle this anxiety; it will be over shortly." This statement reflects positive self-talk by acknowledging the anxiety but also affirming the client's ability to cope and that the situation is temporary. This empowers the client to manage the panic attack effectively.
Incorrect Choices:
A: "I am feeling very nervous right now." This choice focuses only on acknowledging the feeling without providing a positive coping strategy.
C: "I am taking medication to eliminate these symptoms." This choice relies solely on medication and does not address the client's ability to cope with the panic attack.
D: "Relax your muscles, relax your muscles." This choice provides a relaxation technique but lacks the empowering and affirming aspect of positive self-talk.
A staff nurse on a psychiatric unit knows that patients often have trouble sleeping because of their psychiatric conditions. Which of the following would reflect a psychiatric nursing intervention to appropriately address this problem?
- A. Limiting amounts of evening snacks and beverages
- B. Involving patients in a volleyball game immediately before bedtime
- C. Enforcing the rule that all patients be in bed with lights out by 10:30 PM
- D. Encouraging patients to take short naps in the afternoons
Correct Answer: A
Rationale: Correct Answer: A: Limiting amounts of evening snacks and beverages
Rationale:
1. Limiting evening snacks and beverages can help regulate patients' sleep patterns by reducing stimulants that may interfere with sleep.
2. Nutrition plays a role in sleep quality, and avoiding heavy meals close to bedtime can promote better sleep.
3. This intervention addresses a common issue in psychiatric patients without imposing strict rules or physical activity.
4. It focuses on a holistic approach to improving sleep quality by considering dietary factors.
Summary:
B: Involving patients in a volleyball game immediately before bedtime - This choice is incorrect as vigorous physical activity before bedtime can be stimulating and may disrupt sleep.
C: Enforcing the rule that all patients be in bed with lights out by 10:30 PM - This choice is incorrect as it is too rigid and may not address the underlying causes of sleep disturbances.
D: Encouraging patients to take short naps in the afternoons - This choice is incorrect as daytime