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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.
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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.
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.
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.
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.
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.