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Which nursing intervention would be most helpful for addressing this behavior?
- A. Hold a weekly staff meeting to discuss feelings and conflicts related to such behavior.
- B. Confront the patient and advise her that if she continues this, she will lose privileges.
- C. Get all staff to agree that any and all inappropriate behavior will simply be ignored.
- D. Evaluate the patient for a medication increase or transfer to a long-term facility.
Correct Answer: A
Rationale: The correct answer is A because holding a weekly staff meeting to discuss feelings and conflicts related to the behavior promotes open communication and teamwork. This intervention allows staff to address the behavior in a collaborative and supportive manner, leading to a better understanding of the underlying issues and potential solutions.
Choice B is not the best option as confronting the patient may escalate the situation and create a power struggle, potentially worsening the behavior. Choice C of ignoring inappropriate behavior can lead to a lack of accountability and enable further misconduct. Choice D of evaluating the patient for a medication increase or transfer may not address the root cause of the behavior and could overlook the importance of addressing it through communication and teamwork.
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Which statement by a patient with borderline personality disorder best indicates the treatment plan is helping?
- A. I think you are the best nurse on the unit.'
- B. I hate my doctor. He never gives me what I ask for.'
- C. I feel empty and want to cut myself, so I called you.'
- D. I'm never going to get high on drugs again.'
Correct Answer: C
Rationale: The correct answer is C. This statement indicates progress because the patient is demonstrating insight into their emotions, seeking help, and utilizing a coping strategy by reaching out for support instead of engaging in self-harm. Choice A does not provide information about progress in treatment. Choice B reflects a negative attitude towards the doctor. Choice D does not offer any insight into the patient's emotional state or progress in managing their behaviors.
A patient diagnosed with schizophrenia reveals to the nurse that voices have warned of danger and adds, 'They're so loud they frighten me. Do you hear them?' The nurse's best initial response would be:
- A. I know these voices are very real to you, but I don't hear them.'
- B. Don't worry. You're safe in the hospital. I won't let anything happen to you.'
- C. Tell me more about the voices. Are they men or women? How many are there?'
- D. What do you do in order to keep yourself occupied so you don't hear the voices?'
Correct Answer: A
Rationale: The correct answer is A because it acknowledges the patient's experience without dismissing or invalidating it. By stating, "I know these voices are very real to you, but I don't hear them," the nurse validates the patient's reality and expresses empathy. This response helps build trust and rapport, which is crucial in establishing a therapeutic relationship.
Choice B is incorrect because it dismisses the patient's concerns and offers false reassurance, which may not be effective in addressing the patient's distress.
Choice C is incorrect as it focuses on gathering more information about the voices without addressing the patient's immediate emotional distress.
Choice D is incorrect because it shifts the focus away from the patient's current experience and onto distractions, which may not be helpful in addressing the patient's distressing symptoms.
A patient is admitted to the inpatient unit with a diagnosis of schizophrenia. The patient has had episodes of school absenteeism, withdrawal from friends, and bizarre behavior, including talking to his or her 'keeper.' The psychiatric-mental health nurse's most appropriate response is to:
- A. acknowledge that the patient's perceptions seem real to him or her, and refocus the patient's attention on a task or activity
- B. encourage the patient to express his or her thoughts, to determine the meaning they have for the patient
- C. ignore the patient's bizarre behavior, because it will diminish after he or she has been given the correct medication
- D. inform the patient that his or her perceptions of reality have become distorted because of the illness
Correct Answer: A
Rationale: Validating the patient's experience while redirecting to reality-based activity builds trust and reduces agitation without confrontation.
A client with antisocial personality disorder yells, 'Shut up about that, or I'll punch you in the nose!' and shakes his fist at another client in a group meeting after the client speaks negatively of illicit drug use. The nurse quickly determines that the client is at risk to act violently against others as evidenced by his aggressive behavior, verbal threats, and a history of impulsivity. Which is the best approach for the nurse to use?
- A. Seclude the client to protect the other clients and staff.
- B. Put the client in restraints to protect the milieu.
- C. Explore alternate ways to handle frustrating topics in the group.
- D. Tell the client to leave the group until he can behave appropriately.
Correct Answer: C
Rationale: The correct answer is C: Explore alternate ways to handle frustrating topics in the group. This approach is best because it focuses on addressing the underlying issue causing the client's aggression rather than just isolating or restraining the client. By exploring alternate ways to handle frustrating topics, the nurse can help the client develop healthier coping mechanisms and communication skills. This approach promotes therapeutic engagement and supports the client's growth and development.
Secluding the client (choice A) may escalate the situation and reinforce the client's aggressive behavior. Putting the client in restraints (choice B) is a restrictive measure that should only be used as a last resort for imminent danger. Telling the client to leave the group (choice D) may not address the root cause of the aggression and could lead to avoidance of addressing the client's issues.
DSM stands for
- A. diagnostic schedule of medicine
- B. diagnostic and statistical manual
- C. depressive scale modalities
- D. doctor of surgical medicine
Correct Answer: B
Rationale: DSM refers to the Diagnostic and Statistical Manual of Mental Disorders, a key classification tool.