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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.
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The nurse is reviewing the drawing that a patient completed as a self-portrait. The nurse observes that the drawing lacks arms and feet. The nurse interprets this as indicating which of the following? Select all that apply.
- A. Low self-esteem
- B. Powerlessness
- C. Insecurity
- D. Inadequacy
Correct Answer: A,B,C,D
Rationale: In psychiatric art assessment, missing body parts like arms and feet can indicate low self-esteem (A), powerlessness (B), insecurity (C), and inadequacy (D), reflecting feelings of incompleteness or diminished self-worth. All apply based on standard interpretations.
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.
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.
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: Limiting evening snacks and beverages, especially those with caffeine, promotes sleep hygiene by reducing stimulants and bladder disturbances, addressing sleep issues common in psychiatric conditions. Volleyball before bed may increase arousal, enforcing bedtime is rigid and non-therapeutic, and naps can disrupt nighttime sleep.
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.