Nokea
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.
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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.
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.
After teaching a group of nursing students about milieu therapy, the instructor determines that additional teaching is needed when the students identify which of the following as a key concept of milieu therapy?
- A. Structure interaction
- B. Open communication
- C. Validation
- D. De-escalation
Correct Answer: D
Rationale: Milieu therapy emphasizes a therapeutic environment with structured interaction (A), open communication (B), and validation (C) to promote healing. De-escalation (D) is a specific intervention, not a core concept of milieu therapy, indicating a need for further review.
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.
A nurse identifies a nursing diagnosis of chronic low self-esteem. Which statement by a patient would support this nursing diagnosis?
- A. I feel so ugly.'
- B. No one wants to date me.'
- C. I?m so fat, like a cow.'
- D. I never do anything right.'
Correct Answer: A,B,C,D
Rationale: All statements reflect negative self-perception, supporting chronic low self-esteem: feeling ugly (A), undesirable (B), physically flawed (C), and incompetent (D). Each directly indicates diminished self-worth, a hallmark of the diagnosis.