A nurse is assessing a patient?s spirituality. Which question would be most appropriate to ask?
- A. Have you ever tried to harm yourself?
- B. How important is your family to you?
- C. How do you define good and evil?
- D. What gives your life meaning?
Correct Answer: D
Rationale: Spirituality involves beliefs and values that provide meaning and purpose. 'What gives your life meaning?' directly explores spiritual perspectives. Suicide risk (A) is psychological, family importance (B) is social, and good vs. evil (C) is philosophical but less central to spirituality.
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A nurse is performing a biopsychosocial assessment of a patient with depression. Which of the following would the nurse assess as part of the psychological domain? Select all that apply.
- A. Abstract reasoning
- B. Medication use
- C. Mood
- D. Orientation
- E. Self-care
Correct Answer: A,C,D
Rationale: The psychological domain includes cognitive and emotional functions such as abstract reasoning (A), mood (C), and orientation (D). Medication use (B) is part of the biological domain, and self-care (E) relates to the social or functional domain.
Based on assessment data, the nurse formulates the nursing diagnosis for a patient as sleep pattern disturbance. After teaching the patient how to relax before bedtime, the nurse determines that the teaching was effective by which outcome?
- A. Discusses feelings about not being able to fall asleep
- B. Reports feeling rested on awakening in the morning within 3 days
- C. Requests sleeping medication each night before bedtime
- D. Is able to sleep for short intervals throughout the night
Correct Answer: B
Rationale: The goal of teaching relaxation techniques is to improve sleep quality. 'Reports feeling rested on awakening in the morning within 3 days' directly indicates effective sleep, aligning with the intervention?s purpose. Discussing feelings, requesting medication, or short sleep intervals do not confirm improved sleep quality.
A patient is being admitted to the psychiatric unit. While explaining his reason for seeking admission, he describes how his 32-year-old son recently died of a heart attack. Which response by the nurse would enhance the effectiveness of this interview?
- A. How is your wife handling your son?s death?
- B. Do you have any other living children that can help you cope with this loss?
- C. This must be a very difficult time for you.
- D. I know exactly how you?re feeling; my 23-year-old son died unexpectedly last year.
Correct Answer: C
Rationale: A therapeutic response acknowledges the patient?s emotions and fosters rapport. 'This must be a very difficult time for you' reflects empathy and encourages further sharing. Options A and B shift focus to others, and option D involves inappropriate self-disclosure, which may detract from the patient?s needs.
A patient is engaged in bibliotherapy and begins to express his feelings because he closely associates his experience with that provided by the reading material. The nurse interprets this as which of the following?
- A. Insight
- B. Catharsis
- C. Anxiety reduction
- D. Problem solving
Correct Answer: B
Rationale: Bibliotherapy involves emotional release through relating to reading material. The patient?s expression of feelings indicates catharsis, the release of pent-up emotions. Insight involves understanding, anxiety reduction is a secondary effect, and problem-solving involves action planning.
A patient was admitted to the hospital after a suicide attempt made after his daughter was killed in an automobile accident during which he had been driving and survived with only minor injuries. Even though the accident was unavoidable, he feels responsible. During the assessment interview, the patient begins to describe the last conversation he had with his daughter before he lost control of the automobile. As he speaks about his daughter, his voice trembles, and a silent tear rolls down his face. He makes a visible attempt to straighten up and smiles superficially at the nurse, stating, 'I?ll get over this. I just need to keep a stiff upper lip. I think all I need to do is stay overnight. I?ll be as good as new by tomorrow.' Which response by the nurse would be most appropriate?
- A. Tell me about your daughter. How would you describe the relationship you had with her?
- B. I?m sure you are right; a good night?s rest should make a big difference.
- C. As good as new?
- D. You made a serious attempt on your life; you will not be ready go home by tomorrow.
Correct Answer: C
Rationale: The patient?s statement reflects minimization or denial of his emotional distress and suicide attempt. Using reflection, 'As good as new?' prompts the patient to explore his feelings further without judgment. Option A shifts focus prematurely, option B reinforces denial, and option D is confrontational, potentially shutting down communication.
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