Nokea
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.
You may also like to solve these questions
An outcome for a patient experiencing anticipatory grieving for a spouse diagnosed with
terminal cancer would be that the patient will:
- A. Continue to be emotionally involved with the dying spouse
- B. Develop protective mental mechanisms to allay the pain of spousal loss
- C. Not voice threats of physical violence that is either self or others directed
- D. Agree to stay at home and care for the spouse with appropriate assistance
Correct Answer: D
Rationale: Anticipatory grieving involves preparing emotionally for the upcoming loss. The patient may begin to focus on caregiving and emotional preparation. Agreeing to care for the spouse with assistance reflects an adaptive coping mechanism during this period.
A novice mental health nurse shares that, “I’ll never get used to playing cards or other games with patients. It seems like a poor use of scarce nursing time.” The best response for the nurse’s mentor would be:
- A. “Perhaps you’ll want to rethink your transfer to this unit if you’re really uncomfortable.”
- B. “Your comments make a point about scarce resources. I’ll ask the treatment team to review our position on activities.”
- C. “Activity co-leadership puts us in a position to help patients develop social skills and support them as they take small risks.”
- D. “Managed care has cost us activities therapists. Activities are
Correct Answer: C
Rationale: The best response for the nurse’s mentor would be to highlight the importance of activities in mental health nursing. Participating in activities such as playing cards or games with patients is not just about passing time, but it also serves a therapeutic purpose. Engaging in activities helps patients to develop social skills, build relationships, and take small risks in a safe environment. As mental health nurses, it is crucial to understand that these activities are not a waste of time but rather an essential part of the therapeutic process. By participating in activities with patients, nurses can actively support their mental well-being and contribute to their overall treatment and recovery.
The physician has ordered atropine 5 mg intramuscularly (IM) for a patient to be administered 30 minutes prior to ECT. The rationale for use of this medication is that it reduces secretions and:
- A. Improves the scope of convulsive activity
- B. Reduces the need for recovery room staff
- C. Prevents incontinence of bladder and bowel
- D. Increases the patient's alertness post-procedure.
Correct Answer: A
Rationale: The rationale for using atropine 5 mg IM prior to ECT is to protect against vagal bradycardia, not to improve the scope of convulsive activity, reduce the need for recovery room staff, or prevent incontinence of bladder and bowel. Atropine is a muscarinic antagonist that blocks the effects of acetylcholine on muscarinic receptors, leading to an increase in heart rate and protection against bradycardia that can occur during ECT.
When asked, the nurse explains that grief work refers to:
- A. Establishing new methods of coping with stress
- B. Evaluating progress made toward accepting the loss
- C. The means by which one moves through the grief process
- D. Actively seeking assistance to cope with the loss experiences
Correct Answer: C
Rationale: Grief work involves actively processing emotions, integrating the loss, and adapting to life without the deceased. It is not solely about stress coping or progress evaluation.
A friend says to a nurse, “I am not going to get vaccines for my baby. I hear that vaccines cause autism.” The nurse’s best reply is:
- A. The exact cause of autism is not really known
- B. It’s believed that autism is really a result of birth trauma
- C. There is no conclusive evidence to connect autism to vaccinations.
- D. Please tell me more about where you got that information about autism?
Correct Answer: C
Rationale: This response provides factual, evidence-based information to address the common misconception linking vaccines to autism. It is clear and reassuring for the parent.