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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.
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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.
The nurse is reviewing the assessment data of a patient diagnosed with a mental illness. The patient is to be prescribed medication to treat the illness. The nurse would identify changes in which laboratory values as being the least significant?
- A. Hemoglobin
- B. Alanine aminotransferase (ALT)
- C. Blood urea nitrogen (BUN) level
- D. Serum creatinine
Correct Answer: A
Rationale: Hemoglobin levels, related to oxygen-carrying capacity, are less directly relevant to psychiatric medication management compared to liver function (ALT) and kidney function (BUN, creatinine), which affect drug metabolism and excretion. Abnormal hemoglobin may indicate anemia but is less critical for psychotropic drugs.
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.
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.
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.