Nokea
Which assessment finding for a patient living in the community requires priority intervention by the nurse?
- A. Receives Social Security disability income plus a small check from a trust fund.
- B. Lives in an apartment with two patients who attend day hospital programs.
- C. Has a sibling who is interested and active in care planning.
- D. Purchases and uses marijuana on a frequent basis.
Correct Answer: D
Rationale: Patients who regularly buy illegal substances often become medication noncompliant. Medication noncompliance, along with the disorganizing influence of illegal drugs on cellular brain function, promotes relapse. The remaining options do not suggest problems.
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A patient diagnosed with schizophrenia has been stable in the community. Today, the spouse reports the patient is expressing delusional thoughts. The patient says, 'I'm willing to take my medicine, but I forgot to get my prescription refilled.' Which outcome should the nurse add to the plan of care?
- A. Nurse will obtain prescription refills every 90 days and deliver them to the patient.
- B. Patient's spouse will mark dates for prescription refills on the family calendar.
- C. Patient will report to the hospital for medication follow-up every week.
- D. Patient will call the nurse weekly to discuss medication-related issues.
Correct Answer: B
Rationale: The nurse should use the patient's support system to meet patient needs whenever possible. Delivery of medication by the nurse should be unnecessary if the patient or a significant other can be responsible. The patient may not need more intensive follow-up as long as he or she continues to take the medications as prescribed. No patient issues except failure to obtain medication refills were identified.
A nurse assesses an inpatient psychiatric unit, noting that exits are free from obstruction, no one is smoking, the janitor's closet is locked, and all sharp objects are being used under staff supervision. These observations relate to what nursing responsibility?
- A. Management of milieu safety
- B. Coordinating care of patients
- C. Management of the interpersonal climate
- D. Use of therapeutic intervention strategies
Correct Answer: A
Rationale: Members of the nursing staff are responsible for all aspects of milieu management. The observations mentioned in this question directly relate to the safety of the unit. The other options, although part of the nurse's concerns, are unrelated to the observations cited.
A community psychiatric nurse assesses that a patient diagnosed with a mood disorder is more depressed than on the previous visit a month ago; however, the patient says, 'I feel the same.' Which intervention supports the nurse's assessment while preserving the patient's autonomy?
- A. Arrange for a short hospitalization.
- B. Schedule weekly clinic appointments.
- C. Refer the patient to the crisis intervention clinic.
- D. Call the family and ask them to observe the patient closely.
Correct Answer: B
Rationale: Scheduling clinic appointments at shorter intervals will give the opportunity for more frequent assessment of symptoms and allow the nurse to use early intervention. If the patient does not admit to having a crisis or problem, a referral would be useless. The remaining options may produce unreliable information, violate the patient's privacy, and waste scarce resources.
A nurse surveys the medical records for violations of patients' rights. Which finding signals a violation?
- A. No treatment plan is present in record.
- B. Patient belongings were searched at admission.
- C. Physical restraints were used to prevent harm to self.
- D. Patient is placed on one-to-one continuous observation.
Correct Answer: A
Rationale: The patient has the right to have a treatment plan. Inspecting a patient's belongings is a safety measure. Patients have the right to a safe environment, including the right to be protected against impulses to harm self that occur as a result of a mental disorder.
The following patients are seen in the emergency department. The psychiatric unit has one bed available. The patient demonstrating which problem should the admitting officer recommend for admission to the hospital?
- A. Experiencing dry mouth and tremor related to side effects of haloperidol
- B. Experiencing anxiety after divorcing a spouse after 10 years of marriage
- C. Has a self-inflicted a superficial cut on the forearm after a family argument
- D. Has begun hearing voices encouraging her to, 'Smother your infant'
Correct Answer: D
Rationale: Admission to the hospital would be justified by the risk of patient danger to self or others. The other patients have issues that can be handled with less restrictive alternatives than hospitalization.