Nokea
The expected outcome for a patient with a nursing diagnosis of disturbed thought processes is:
- A. The patient will be safe from injury.
- B. The patient will meet basic biological needs.
- C. The patient will achieve optimum cognitive functioning.
- D. The patient will maintain positive interpersonal relationships.
Correct Answer: C
Rationale: The correct answer is C because disturbed thought processes indicate cognitive impairment. Thus, the expected outcome should focus on improving cognitive functioning to achieve optimal mental clarity and decision-making. Safety (A) is important but not directly related to cognitive improvement. Meeting basic needs (B) and maintaining relationships (D) are important but not the primary focus when the diagnosis is disturbed thought processes. So, the priority is on enhancing cognitive functioning to address the root cause of the issue.
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A child, age 5, was admitted to the children's unit, having been sexually abused by an acquaintance of her family. The child refuses to talk and participate in unit activities, choosing to stay in her room with her stuffed animals. Which therapeutic intervention will best help the child release pent-up feelings about the abuse?
- A. Individual communication with the nurse
- B. Play therapy
- C. Family therapy
- D. Role-play with other children on the unit
Correct Answer: B
Rationale: The correct answer is B: Play therapy. Play therapy is the most suitable therapeutic intervention for a child in this scenario because it allows the child to express their feelings and experiences through play, which is a natural form of communication for children. Through play therapy, the child can act out their experiences using toys and create a safe space to process their emotions without having to verbally communicate. It helps the child release pent-up feelings and trauma in a non-threatening environment.
Summary of other choices:
A: Individual communication with the nurse may not be as effective as play therapy in this case as the child is not yet comfortable verbalizing their feelings.
C: Family therapy may not be appropriate at this stage as the child is not ready to engage with family members about the abuse.
D: Role-play with other children on the unit may not be beneficial as it can potentially trigger more anxiety and discomfort for the abused child.
An outpatient diagnosed with schizophrenia attends programming at a community mental health center. The patient says, I threw away the pills because they keep me from hearing God. Which response by the nurse would most likely to benefit this patient?
- A. You need your medicine. Your schizophrenia will get worse without it.
- B. Do you want to be hospitalized again? You must take your medication.
- C. I would like you to come to the medication education group every Thursday.
- D. I noticed that when you take the medicine, you have been able to hold a job you wanted.
Correct Answer: D
Rationale: Connecting medication to the patient's goal (job) (D) motivates adherence despite desirable hallucinations. Exhortations (A, B) ignore insight issues, and education (C) assumes a knowledge deficit, not the core problem.
A patient living independently had command hallucinations to shout warnings to neighbors. After a short hospitalization, the patient was prohibited from returning to the apartment. The landlord said, 'You cause too much trouble.' What problem is the patient experiencing?
- A. Grief
- B. Stigma
- C. Homelessness
- D. Nonadherence
Correct Answer: B
Rationale: The inability to obtain shelter because of negative attitudes about mental illness is an example of stigma. Stigma is defined as damage to reputation, shame, and ridicule society places on mental illness. Data are not present to identify grief as a patient problem. Data do not suggest that the patient is actually homeless.
The nurse performs a functional assessment of a client upon admission to a home health service. The purpose of this assessment is to determine the client's:
- A. Level of consciousness
- B. Ability to perform activities of daily living
- C. Degree of reasoning, judgment, and thought processes
- D. Level of functioning memory
Correct Answer: B
Rationale: The correct answer is B: Ability to perform activities of daily living. A functional assessment in home health services focuses on evaluating the client's ability to independently perform daily tasks such as bathing, dressing, and preparing meals. This assessment helps determine the client's level of independence and need for assistance. Choices A, C, and D are incorrect because they do not directly assess the client's ability to perform activities of daily living, which is the primary purpose of a functional assessment in this context.
When a patient with a personality disorder uses manipulation as a way of getting needs met, the staff agree to use limit setting as an intervention. How does limit setting work to reduce manipulation?
- A. Limit setting indulges the patient's desire for attention from staff.
- B. It gives the patient a different concern on which to focus his anger.
- C. External controls provide security while internal controls are developing.
- D. When staff limit the patient's behavior, he is no longer anxious about it.
Correct Answer: C
Rationale: Correct Answer: C
Rationale:
1. External controls, like limit setting, provide structure and predictability for the patient.
2. This security allows the patient to gradually develop internal controls to manage their behavior.
3. By relying on external limits, the patient's need for manipulation decreases over time.
4. This approach fosters growth and autonomy in the patient, reducing the reliance on manipulative behaviors.
Summary:
A: Incorrect. Limit setting does not indulge attention-seeking behaviors; it establishes boundaries.
B: Incorrect. Limit setting does not redirect anger; it focuses on promoting internal control.
D: Incorrect. Limit setting does not solely address anxiety; it aims to foster self-regulation.