Nokea
The community health nurse is visiting a patient diagnosed with dysfunctional grieving since the death of his wife and child over a year ago. Which actions should the nurse implement first?
- A. Promote interaction with others.
- B. Assess risk of self-directed violence.
- C. Facilitate expression of feelings related to the loss.
Correct Answer: B
Rationale: Assessing the risk of self-directed violence is the priority when dealing with a patient diagnosed with dysfunctional grieving. Individuals experiencing complicated grief may be at an increased risk for self-harm or suicidal ideation. By assessing the risk of self-directed violence first, the nurse can ensure the patient's safety and provide appropriate interventions if necessary. Once the risk is assessed and managed, the nurse can then proceed with other interventions such as promoting interaction with others and facilitating the expression of feelings related to the loss.
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A 76-year-old is regressed, indifferent, and responds to others only when they initiate an interaction. What form of group therapy would be most useful to promote resocialization?
- A. Remotivation
- B. Activity group
- C. Psychotherapy
- D. Reminiscence (life review)
Correct Answer: A
Rationale: Remotivation therapy focuses on stimulating engagement and interaction in patients who are socially withdrawn or have limited emotional responses. It helps the individual reconnect with their environment and others.
A 19-year-old patient with undifferentiated schizophrenia is acutely psychotic. The nurse assesses the primary deficit as:
- A. Social isolation
- B. Disturbed thinking
- C. Altered mood states
- D. Poor impulse control
Correct Answer: B
Rationale: Acute psychosis primarily affects thought processes, evidenced by delusions or disorganized thinking.
The treatment team was engaged in planning how group therapy could be included as a part of the structured daily activities of the unit. A new team member asked, “Why is it so important to include group therapy for the patients?” The most accurate response would be based on the assumption that:
- A. Hidden agendas frequently surface in group sessions.
- B. Some persons do not relate well on an individual therapy
- C. Psychopathology has its source in disordered relationships.
- D. Group therapy is far more cost effective for the patients.
Correct Answer: D
Rationale: Group therapy is important because psychopathology often has its roots in disordered relationships. Many mental health issues are influenced by one's interactions with others, whether it be issues with communication, trust, boundaries, or other relational dynamics. Group therapy provides a structured environment where patients can explore and work through these relational difficulties with the support and feedback of peers. By addressing these relational patterns in a group setting, patients can gain insight into their behavior and develop healthier ways of relating to others. This can be a valuable component of their overall treatment plan and can help facilitate lasting change and growth.
The desired outcome for a patient experiencing insomnia is, "Patient will sleep for a minimum of 5 hours nightly within 7 days." At the end of 7 days, review of sleep data shows the patient sleeps an average of 4 hours nightly and takes a 2-hour afternoon nap. What is the nurse’s next action?
- A. Continue the current plan without changes.
- B. Remove this nursing diagnosis from the plan of care.
- C. Write a new nursing diagnosis that better reflects the problem.
- D. Examine interventions for possible revision of the target date.
Correct Answer: D
Rationale: When goals are partially met, the plan of care should be re-evaluated, and adjustments should be made to interventions or timelines.
Which response is appropriate when a patient’s mother expresses guilt over causing my child to be schizophrenic?
- A. I can see how you would be upset over this turn of events
- B. New findings suggest this disorder is biological in nature.
- C. Don’t be so hard on yourself; your daughter needs you to be strong
- D. It’s difficult to see what produces stress for the child at the time it’s occurring.
Correct Answer: B
Rationale: Schizophrenia is primarily linked to biological factors, including genetic predispositions, neurochemical imbalances, and brain structure abnormalities. This response helps dispel guilt and provides reassurance to the mother.