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Which assessment observation supports a patient’s diagnosis of disorganized schizophrenia?
- A. Reports suicidal ideations
- B. Last relapse was 6 years ago
- C. Consistent inappropriate laughing
- D. Believes that the government is out to get me
Correct Answer: C
Rationale: The correct answer is C because consistent inappropriate laughing is a characteristic symptom of disorganized schizophrenia. This observation aligns with the disorganized behavior and affect commonly seen in this subtype of schizophrenia. Option A is not specific to disorganized schizophrenia. Option B does not directly relate to disorganized symptoms. Option D suggests paranoia, which is more indicative of paranoid schizophrenia rather than disorganized schizophrenia.
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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.
Correct Answer: C
Rationale: The correct answer is C because "grief work" refers to the psychological process of actively working through and resolving the emotions and thoughts associated with a loss. This involves facing and processing the feelings of grief rather than avoiding them, ultimately leading to acceptance and healing. Choice A is incorrect as it focuses on coping with stress, not specifically grief. Choice B is incorrect as it emphasizes evaluating progress rather than the process of grieving itself. Choice D is incorrect as it pertains to seeking assistance, which is a part of coping but not the definition of grief work.
Which intervention will the nurse planning care for a patient with acute grief implement?a. Providing information about the grief process
- A. Providing information about the grief process.
- B. Suggesting utilization of community resources in a few weeks
- C. Encouraging dependence on the nurse for support
- D. Assessing for signs of complicated grief or depression
Correct Answer: A
Rationale: The correct answer is A because providing information about the grief process helps the patient understand their feelings and reactions, promoting emotional healing. Choice B is incorrect because suggesting community resources may not address the patient's immediate needs. Choice C is incorrect as encouraging dependence on the nurse may hinder the patient's ability to cope independently. Choice D is incorrect because assessing for complicated grief or depression is important but not the initial intervention in planning care for acute grief.
A patient begins a new program to assist with building social skills. In which part of the plan of care should a nurse record the item, Encourage patient to attend one psychoeducational group daily?
- A. Assessment
- B. Implementation
- C. Analysis
- D. Evaluation
Correct Answer: B
Rationale: The correct answer is B: Implementation. In the nursing process, implementation involves putting the plan of care into action. Encouraging the patient to attend a psychoeducational group daily is an action that is carried out as part of the plan to build social skills. This step focuses on executing interventions to achieve the desired outcomes. In contrast, assessment (A) involves collecting data, analysis (C) involves interpreting data, and evaluation (D) involves determining the effectiveness of interventions. Therefore, the correct placement for recording this item is in the implementation phase.
Which behavior best supports the diagnosis of attention-deficit/hyperactivity disorder in an 8-year-old child?
- A. Cries when separated from his mother or father
- B. Refuses to pick up toys as instructed by his parents
- C. Is fascinated with spinning and moving toys and objects
- D. Can concentrate on schoolwork for only very short periods of time.
Correct Answer: D
Rationale: The correct answer is D because the inability to concentrate for extended periods is a key characteristic of ADHD. This behavior aligns with the inattention aspect of the disorder. Choice A is incorrect as separation anxiety does not directly relate to ADHD. Choice B could indicate oppositional behavior rather than ADHD. Choice C suggests sensory-seeking behavior, which is not a defining feature of ADHD.
When a novice nurse asks why the unit has a multidisciplinary approach to therapeutic activities, the nurse should explain that multidisciplinary collaboration:
- A. Reduces the incidence of aggressive behavior by patients
- B. Produces quicker results and earlier discharge to the community
- C. Produces better outcomes than when only one perspective is used
- D. Helps to improve staffing efficiency and resource allocation.
Correct Answer: C
Rationale: Rationale for Correct Answer (C): Multidisciplinary collaboration in therapeutic activities involves the input of professionals from various disciplines, leading to a holistic approach that considers all aspects of a patient's condition. This approach is more likely to result in better outcomes because it combines diverse perspectives, expertise, and skills to address complex patient needs comprehensively.
Summary of Incorrect Choices:
A: Reducing aggressive behavior is not the primary goal of multidisciplinary collaboration in therapeutic activities.
B: While multidisciplinary collaboration may lead to efficient care, the primary focus is on achieving better outcomes rather than quicker discharge.
D: Although improving staffing efficiency and resource allocation may be benefits of multidisciplinary collaboration, the main purpose is to enhance patient care outcomes through diverse perspectives and expertise.