Mental Health Hardest Test! Trivia Quiz

The nurse's most appropriate response is "Are you thinking of harming yourself?" because the victim expressed feelings of hopelessness and mentioned that there is no reason to go on. This response shows concern for the victim's well-being and acknowledges the possibility of suicidal thoughts, which is important in assessing the level of risk and ensuring appropriate intervention is provided if needed.

The priority intervention for a rape victim who was given flunitrazepam (Rohypnol) by the assailant is monitoring for respiratory depression. Flunitrazepam is a benzodiazepine that can cause central nervous system depression, including respiratory depression. This can be life-threatening and requires immediate attention. Coma, seizures, and hypotonia may also occur as a result of the drug, but respiratory depression poses the greatest immediate risk to the patient's life.

The correct answer is "Volatile: unresolved and unresigned." This motif is evident in the patient's statement about how their cancer spread quickly and how their whole life has been sabotaged, indicating a sense of unresolved anger, frustration, and lack of acceptance. This suggests that the patient is not resigned to their fate and is still grappling with the emotional and psychological impact of their illness.

Creating a scholarship fund at their child's high school indicates adaptive mourning because it shows that the parents are finding a positive way to remember and honor their child's memory. By creating a scholarship fund, they are helping other students and contributing to their child's school community, which can bring a sense of purpose and healing during the grieving process. This behavior also shows resilience and a desire to make a difference in their child's name.

The patient's statement indicates that they are able to remember the good times without getting upset and are even thinking about the disappointments. They also mention that they are still trying to become accustomed to sleeping alone. These statements suggest that the patient has already gone through the process of mourning and is at or near completion.

This finding indicates successful completion of an individual's grieving process because it shows that the widower is able to remember the positive and negative aspects of his relationship with his wife in a realistic manner. This suggests that he has come to terms with the loss and has processed his emotions, allowing him to reflect on the past without being overwhelmed by grief.

The behavior that indicates the child's parents are mourning in an effective way is forbidding their other children from going swimming. This behavior shows that the parents are taking precautions to ensure the safety of their remaining children and are actively trying to prevent a similar tragedy from happening again.

The correct answer is "Patients in the end stage of any disease are eligible." This answer is correct because hospice care is not limited to patients with cancer. Hospice care is provided to individuals who are in the final stages of any disease, regardless of the specific diagnosis. Hospice care focuses on providing comfort and support to patients and their families during this difficult time.

Some people are biologically predisposed to become irritated or angry more easily. This statement accurately serves as a basis for care planning because it recognizes that aggression can be influenced by biological factors. Understanding this predisposition can help healthcare professionals develop appropriate interventions and strategies to manage and prevent aggressive behaviors in individuals who are more prone to becoming easily irritated or angry.

Based on the patient's history of breaking windows in his former girlfriend's home and his previous arrest for disorderly conduct, it is evident that he has a risk for other-directed violence. This behavior suggests that he may pose a threat to others, specifically his former girlfriend. Therefore, the priority nursing diagnosis should be focused on assessing and managing this risk to ensure the safety of both the patient and others.

Before following the patient into the day room, the most important intervention would be to assure that adequate staff are available and nearby for backup. The patient's aggressive behavior indicates a potential risk of violence, and having enough staff present ensures the safety of both the patient and the nurse. It allows for immediate assistance if the situation escalates and helps prevent any harm or injury. Contacting the patient's physician, reviewing the patient's history, and preparing a sedative may be important interventions as well, but ensuring the presence of sufficient staff is the priority in this situation.

A unit that is adequately staffed and not overcrowded is likely to result in a low incidence of violent behavior because having enough staff ensures that patients receive appropriate care and attention, reducing the likelihood of conflicts or aggression. Additionally, an overcrowded unit can create a stressful and tense environment, increasing the chances of violent behavior.

The correct answer is "You want to go home to get your husband’s dinner." This response acknowledges and validates the patient's feelings and desires, demonstrating understanding and empathy. By affirming the patient's need to go home and prepare dinner for her husband, the nurse is using validation therapy to validate the patient's reality and help her feel heard and understood. This approach can help reduce the patient's anxiety and agitation, promoting a sense of calm and well-being.

Periodically updating the husband about his wife and what is being done for her would best prevent further escalation. This intervention shows empathy and provides the husband with information, helping to alleviate his anxiety and irritability. It keeps him engaged and informed, reducing his feelings of helplessness and frustration. By regularly updating him, the nurse acknowledges his concerns and demonstrates that his wife's care is a priority. This intervention promotes effective communication and helps to maintain a positive and supportive environment in the waiting room.

The correct answer is to choose the least restrictive measure that will keep the patient and others safe. This principle is based on the ethical concept of promoting autonomy and minimizing harm. It recognizes the importance of respecting the patient's rights and dignity while ensuring the safety of everyone involved. By prioritizing the least restrictive intervention, nurses aim to maintain a therapeutic and supportive environment that encourages the patient's sense of control and autonomy. This approach also aligns with the principles of trauma-informed care, which emphasizes the importance of minimizing retraumatization and promoting empowerment.

In this scenario, the patient required seclusion immediately upon entering the inpatient unit. However, the assessment was incomplete and no medical orders had been written. The priority action for the nurse should be to notify the physician and obtain an order for seclusion. This is important to ensure that the patient's safety and well-being are properly addressed and that the appropriate legal and ethical procedures are followed.

The nurse would use the criteria of outcomes developed for each patient to decide when to discontinue the use of seclusion. This means that the decision to discontinue seclusion would be based on the specific goals and progress of the individual patient, rather than a set time frame or the physician's orders.

The nurse should keep in mind that intramuscular injection can be traumatic, so oral medications should be used whenever possible. This means that if there is an option to administer the sedative orally, it should be chosen over the intramuscular route. This is because intramuscular injections can be painful and may cause discomfort for the patient. Using oral medications can provide a more comfortable and less invasive method of administering the sedative.

The patient's passive behavior and difficulty in performing daily activities of living, as well as the expectation for others to provide meals and wash clothes, suggest that the behavior is likely a result of dependency caused by institutionalization. Spending 5 years in a state hospital may have led to the patient becoming accustomed to relying on others for their needs, resulting in a lack of independence and difficulty in determining how to spend their time. This explanation is supported by the information provided in the question.

The patient is demonstrating anosognosia, which is a lack of awareness or denial of their own illness. The patient believes that there is nothing wrong with them and refuses to take medicine because they do not perceive themselves as being sick. They also have delusions that the hospital staff wants to steal their thoughts, which is a symptom of schizophrenia.

The nursing diagnosis that would most likely apply in this situation is "Risk for low self-esteem." This is because the individual's mental illness and subsequent homelessness can lead to feelings of worthlessness and a negative self-perception. The lack of social interaction, inability to meet basic needs, and resorting to stealing further contribute to the risk of low self-esteem.

The team's initial priority should be to interact regularly and supportively without trying to change the individual. This approach can help build a trusting relationship and create a safe and non-judgmental environment for the individual. By establishing a positive rapport, the team can better understand the individual's needs and concerns, which can eventually lead to addressing treatment adherence and other important aspects of their well-being.

The most likely medication strategy that will be used as the patient transitions from the hospital to the community is to involve the patient in the decision about which medication is best. This approach recognizes the patient's autonomy and respects their right to be involved in their own treatment decisions. By involving the patient in the decision-making process, it increases the likelihood of medication adherence and reduces the risk of the patient discontinuing their medication soon after discharge. This collaborative approach also promotes a sense of empowerment and engagement in their own care, which can contribute to better long-term outcomes.

The correct answer reflects the research on mortality and serious mental illness by stating that mentally ill people tend to die much younger than others. This may be due to factors such as not taking good care of their health, smoking more, or being overweight. This explanation suggests that the man's mental illness may have contributed to his premature death.

The correct answer is "Sentencing such persons to participate in treatment instead of incarcerating them has been shown to reduce repeat offenses." This advice is the most appropriate because it acknowledges the connection between mental illness and minor offenses, and recognizes the importance of providing treatment rather than punishment. It suggests that participating in treatment can help address the underlying issues that led to the offense, reducing the likelihood of repeat offenses in the future.

The most helpful intervention for assuring mutual respect within the group would be to describe the importance of mutual respect in the first session and make it a group norm. By explicitly discussing the significance of mutual respect and setting it as a norm from the beginning, the leader establishes a foundation for respectful interactions among group members. This approach helps to create a positive and supportive environment where individuals feel valued and heard, leading to better group dynamics and outcomes.

The correct answer is "You are wondering whether I have enough experience to lead this group." This response acknowledges the patient's concern and addresses it directly. It shows empathy and invites the patient to express their thoughts and concerns further, allowing for open communication and building trust between the nurse and the patient.

The patient's remark indicates that they have realized that they are not the only one who feels afraid, suggesting that others in the group also share similar fears. This demonstrates universality, which refers to the understanding that one's experiences and feelings are not unique and that others can relate to them.

The correct answer acknowledges the change in behavior of the group members and addresses their potential concerns about the group's progress. By opening up the discussion to the group, the nurse leader allows the members to express their thoughts and feelings, which can help identify any underlying issues and facilitate a more productive group therapy session. This intervention promotes active participation and engagement from all members, rather than singling out Mary or directly confronting her about her excessive talking.

The group approach described in the question focuses on recognizing dysfunctional behavior and thinking patterns and replacing them with more adaptive behaviors and thinking. This aligns with the principles of cognitive-behavioral theory, which emphasizes the relationship between thoughts, feelings, and behaviors and seeks to modify negative or maladaptive thoughts and behaviors.

The correct answer suggests that the three members who share covert glances and make subtle put-downs or objections are forming a subgroup within the therapy group. This subgroup is likely to have its own dynamics and agenda, which may be different from the goals and purpose of the main group. Their behavior indicates that they are not fully participating as members of the main group, but rather engaging in their own separate interactions and dynamics.

The nurse identifies the comment as an example of the group role of encourager because the member is actively promoting and supporting the expression of different feelings within the group. By requesting to hear from individuals who experienced other emotions, the member is encouraging a diverse range of perspectives and emotions to be shared, fostering a supportive and inclusive group environment.

The correct answer is "Energizer" because the phrase "let's speed things up" suggests that the person wants to increase the pace or energy of the decision-making process. An energizer is someone or something that boosts energy or enthusiasm, so choosing this option aligns with the idea of increasing productivity and efficiency.

The statement suggests that the speaker and their team have completed a task or objective (first goal) and are now moving on to another task or objective (second goal). The term "organizer" fits well with this context as it implies someone who plans and coordinates activities, which aligns with the idea of setting and achieving goals.

The most likely explanation for the member's current silence is that he is having difficulty coping with his emotions regarding the group's impending end. This could be causing him to withdraw and become silent, as he may be feeling a sense of loss or sadness.

This response by the leader acknowledges that the end of the group can evoke a range of emotions for everyone involved. By asking each member to share their feelings, it creates a safe space for the quiet member to express themselves and potentially open up about why they have become silent. This response also shows empathy and understanding towards the members, promoting a supportive and inclusive environment.

The new staff nurse can expect an advanced practice nurse to prescribe psychotropic medication because advanced practice nurses have the authority and knowledge to prescribe medications for psychiatric patients. Conducting mental health assessments, establishing therapeutic relationships, and individualizing nursing care plans are all within the scope of practice for a staff nurse and do not require the advanced skills and training of an advanced practice nurse.

The answer explains that psychiatric nurses utilize complex communication skills and critical thinking to solve multi-dimensional problems. This response indicates that the student is interested in the mental health field because they are challenged by these types of situations. It highlights the importance of communication and problem-solving skills in psychiatric nursing, suggesting that it is not just about talking but requires a high level of expertise and adaptability.

The nurses have fulfilled the role of advocacy by writing letters to their elected representatives in opposition to the legislation. Advocacy involves actively supporting or promoting a cause or issue, in this case, the care of persons with mental illness. By expressing their concerns to the lawmakers, the nurses are advocating for the needs and rights of individuals with mental illness and trying to influence the decision-making process regarding funding for their care.

The comment "spends time listening to me talk about my problems. That helps me feel like I’m not alone" best indicates that the patient perceived the nurse as caring because it shows that the nurse is actively engaged in understanding the patient's concerns and providing emotional support. By listening attentively, the nurse creates a sense of companionship and empathy, which is a key aspect of providing caring nursing care.

This answer indicates that a patient has a mental illness because it suggests that the patient is conforming to the rules, routines, and customs of a group without considering their own individuality or personal preferences. This could be a sign of impaired decision-making, lack of autonomy, or difficulty in asserting oneself, which are common symptoms of certain mental illnesses.

The finding that best indicates that the goal "Demonstrate mentally healthy behavior" was achieved is when a patient sees themselves as approaching ideals and capable of meeting demands. This suggests that the patient has a positive self-perception and believes in their own abilities to handle challenges and responsibilities. It reflects a sense of self-confidence and a healthy mindset.

The finding that the patient reports consistently sad, discouraged, and hopeless mood indicates a possible mental illness. This is because these symptoms are commonly associated with conditions such as depression, where individuals experience persistent feelings of sadness and hopelessness. It suggests that the patient may be experiencing emotional distress and may require further evaluation and support.

The nurse should consult the Diagnostic and Statistical Manual of Mental Disorders (DSM) to determine the criteria used to establish the diagnosis of the unfamiliar psychiatric disorder. The DSM is a widely recognized and authoritative resource used by healthcare professionals to diagnose and classify mental disorders. It provides a comprehensive list of diagnostic criteria, descriptions, and codes for various mental health conditions. By referring to the DSM, the nurse can ensure that the diagnosis is accurate and based on standardized criteria.

The nurse would expect documentation of major depression, avoidant personality disorder, hypertension, the fact that the patient's home was destroyed by a hurricane last year, and the patient's blood pressure reading of 80. These are all relevant factors in a psychiatric treatment setting as they provide insight into the patient's mental health, personality traits, physical health condition, and any significant life events that may have contributed to their current state.

The multiaxial DSM-IV-TR is a diagnostic system used in psychiatry to classify mental disorders. It includes five axes, each representing a different aspect of an individual's functioning. The third axis specifically focuses on the classification of problems in multiple areas of functioning, such as social, occupational, and psychological. This axis helps clinicians to assess the overall impact of these problems on the individual's daily life and functioning. Therefore, the statement "classifies problems in multiple areas of functioning" accurately describes the purpose of the multiaxial DSM-IV-TR.

The Diagnostic and Statistical Manual of Mental Disorders (DSM) would have the most complete information regarding the diagnostic criteria for anxiety disorders. The DSM is widely recognized as the authoritative resource for classifying and diagnosing mental disorders, including anxiety disorders. It provides detailed descriptions of various mental disorders, including specific criteria that must be met for a diagnosis to be made. Nurses and other healthcare professionals often refer to the DSM to guide their assessment and treatment of patients with mental health conditions.

The correct answer is "mental disorders people have." The Diagnostic and Statistical Manual of Mental Disorders (DSM) is a widely used classification system for mental disorders. It categorizes and describes various mental disorders that individuals may have. The DSM helps clinicians and researchers in diagnosing and treating mental illnesses by providing a standardized framework. It does not classify deviant behaviors or people with mental disorders as a whole, but rather focuses on the specific mental disorders that individuals may experience. The classification is based on symptoms, impairments, and distress caused by these disorders.

Assessment findings in mental disorders reflect a person's cultural patterns. This belief will best support a nurse's efforts to provide patient advocacy during a multidisciplinary patient care planning session because it recognizes the importance of considering cultural factors when assessing and planning care for individuals with mental disorders. By understanding and respecting a person's cultural background, the nurse can provide more effective and culturally sensitive care, taking into account the unique beliefs, values, and practices that may impact their mental health.

Clinical epidemiology is the study of the patterns, causes, and effects of health and disease conditions in defined populations of patients or groups of patients. In this scenario, the nurse is part of a team that is studying the outcomes of different treatment approaches for depressed patients. This involves analyzing the effectiveness of supportive interventions and antidepressant medication compared to only medication. Therefore, the study described in the scenario is an example of clinical epidemiology.

The patient's statement suggests that they lack autonomy and independence in their life. They rely on their parents to make decisions for them and do not socialize much outside of work. This may lead to a diminished sense of self and a limited self-concept. Therefore, interventions should focus on improving the patient's self-concept, helping them develop a stronger sense of self and autonomy.

Axis III of the DSM contains information about any physical health problems that may affect treatment. This axis is used to record any medical conditions or illnesses that the individual may have, which could impact their mental health or the effectiveness of treatment. By considering physical health problems, the psychiatric nurse can provide holistic care and ensure that any medical conditions are taken into account during treatment planning.

Neurotransmitters are natural chemicals that pass messages between brain cells. This response provides a clear and concise explanation of what neurotransmitters are and their role in the brain. It addresses the patient's question and provides accurate information about the topic.

The nurse's best reply is "PET means positron-emission tomography. An injection is given and images are taken. It shows blood flow and activity in the brain." This answer accurately describes what a PET scan is and how it is performed. It explains that a radioactive substance is injected into the body, which then travels to the brain and emits positrons. These positrons are detected by a scanner, which creates images that show the blood flow and activity in the brain. This information can be helpful in diagnosing and monitoring conditions such as schizophrenia.

A CT scan (computed tomography) is the diagnostic procedure that the nurse should expect to prepare the patient for first. This is because a CT scan can provide detailed images of the brain, allowing the healthcare provider to assess for any signs of infarcts or other abnormalities that may be causing the patient's confusion. CT scans are commonly used to detect changes in brain structure and can help differentiate between different causes of cognitive impairment, such as Alzheimer's disease or multiple infarcts.

When a medication potentiates the action of GABA (gamma-aminobutyric acid), it enhances the inhibitory effects of GABA in the brain. GABA is a neurotransmitter that helps to regulate brain activity and reduce neuronal excitability. By increasing the action of GABA, the medication would have a calming effect on the brain, leading to reduced anxiety. Therefore, the expected effect of administering this medication would be a reduction in anxiety symptoms.

Patients with disorganized thinking associated with schizophrenia often exhibit deficits in executive functioning, which is primarily controlled by the frontal lobe. The frontal lobe is responsible for higher cognitive functions such as decision-making, problem-solving, and planning. Dysfunction in this area of the brain can lead to disorganized thoughts, difficulty in organizing and expressing ideas, and impaired judgment. Neuroimaging studies have shown abnormalities in the frontal lobe in individuals with schizophrenia, supporting the idea that dysfunction in this region contributes to the cognitive symptoms of the disorder.

Neurotransmitter inhibitors that block reuptake prevent the reabsorption of neurotransmitters by the presynaptic neuron, leading to an increased concentration of neurotransmitters in the synaptic gap. This allows the neurotransmitters to remain in the synaptic gap for a longer period of time, increasing their availability for binding to receptor sites on the postsynaptic neuron and enhancing neurotransmission. This can help to compensate for any deficiencies or imbalances in neurotransmitter levels and improve overall synaptic communication within the central nervous system.

The patient's symptoms of restlessness and an uncontrollable need to be in motion are indicative of a condition called akathisia, which is a common side effect of antipsychotic medications that block dopamine receptors. Dopamine-blocking effects can lead to an imbalance of neurotransmitters in the brain, resulting in motor disturbances such as akathisia.

The nurse suspects increased activity of norepinephrine because fear is often associated with the fight-or-flight response, which is mediated by the sympathetic nervous system. Norepinephrine is a neurotransmitter that is released during the fight-or-flight response and is responsible for increasing heart rate and blood pressure.

Benzodiazepines are commonly prescribed for acute anxiety as they have a rapid onset of action and can provide immediate relief. They work by enhancing the effects of a neurotransmitter called gamma-aminobutyric acid (GABA) in the brain, which helps to reduce anxiety and promote relaxation. Tricyclic antidepressants, antipsychotic drugs, and antimanic drugs are not typically used for acute anxiety and may have a slower onset of action.

Sertraline (Zoloft) is an antidepressant medication commonly used to treat depression. Therefore, it is likely that the nurse will provide teaching about this medication to the patient who is hospitalized for severe depression. Chlordiazepoxide (Librium) is a benzodiazepine used to treat anxiety and alcohol withdrawal. Clozapine (Clozaril) is an antipsychotic medication used to treat schizophrenia. Tacrine (Cognex) is a medication used to treat Alzheimer's disease. None of these medications are specifically indicated for the treatment of depression, so teaching about them would not be relevant in this case.

Muscarinic receptor blockade refers to the inhibition of the muscarinic receptors in the body. These receptors are responsible for various functions including saliva production. When these receptors are blocked, it can lead to a reduction in saliva production, resulting in dry mouth. Therefore, the nurse will assess the patient for dry mouth as a potential side effect of the drug causing muscarinic receptor blockade. Gynecomastia, pseudoparkinsonism, and orthostatic hypotension are not directly associated with muscarinic receptor blockade.

Paroxetine is a selective norepinephrine reuptake inhibitor (SNRI). This means that it primarily works by blocking the reuptake of norepinephrine, a neurotransmitter, in the brain, leading to increased levels of norepinephrine. This mechanism of action is different from Tofranil (imipramine), which is a tricyclic antidepressant (TCA). TCAs work by blocking the reuptake of both norepinephrine and serotonin, whereas paroxetine specifically targets norepinephrine reuptake. Therefore, the patient should not assume that they will experience the same side effects as when taking Tofranil.

Anticholinergic side effects are likely when a patient takes fluphenazine (Prolixin). Fluphenazine is a typical antipsychotic medication that works by blocking dopamine receptors in the brain. It also has significant anticholinergic properties, meaning it inhibits the action of acetylcholine, a neurotransmitter involved in various bodily functions. Anticholinergic side effects can include dry mouth, constipation, blurred vision, urinary retention, and confusion. Lithium (Lithobid), buspirone (BuSpar), and risperidone (Risperdal) do not have significant anticholinergic properties and are less likely to cause these side effects.

The instruction to "Report sore throat and fever immediately" has priority when teaching a patient taking clozapine (Clozaril) because these symptoms can indicate a potentially serious side effect called agranulocytosis, which is a severe decrease in white blood cell count. Agranulocytosis can increase the risk of infection, so it is important for the patient to report these symptoms immediately to their healthcare provider for further evaluation and monitoring.

Phenelzine is a monoamine oxidase inhibitor (MAOI) used to treat depression. MAOIs have dietary restrictions because they can interact with certain foods and beverages, leading to a dangerous increase in blood pressure. Therefore, the nurse will order a special diet for the patient taking phenelzine to avoid foods high in tyramine, such as aged cheese, cured meats, and fermented foods. Buspirone, haloperidol, and carbamazepine do not have specific dietary restrictions.

When a patient is taking a drug that inhibits monoamine oxidase (MAO), they are at risk of experiencing a hypertensive crisis if they consume certain foods and drugs. MAO inhibitors prevent the breakdown of certain chemicals in the body, including tyramine. Tyramine can cause a sudden increase in blood pressure when it is not properly metabolized. Certain foods and drugs, such as aged cheese, cured meats, and certain medications, contain high levels of tyramine. If a patient on MAO inhibitors consumes these foods or drugs, it can lead to a hypertensive crisis, which is a severe and potentially life-threatening increase in blood pressure.

A white blood cell count of 3000 mm3 is considered extremely low and can indicate a serious condition called agranulocytosis, which is a potentially life-threatening side effect of clozapine. It is important for the nurse to report these results to the healthcare provider immediately so that appropriate actions can be taken to ensure the patient's safety and well-being.

Valproate (Depakote) belongs to the same group as carbamazepine, lamotrigine, and gabapentin because it is also an antiepileptic medication. These medications are commonly used to treat seizures and certain types of epilepsy. They work by stabilizing abnormal electrical activity in the brain. Galantamine, buspirone, and tacrine are not antiepileptic medications and are used for different purposes such as treating Alzheimer's disease, anxiety, and dementia.

The patient's statement about her husband visiting her in the night suggests that she is experiencing grief over her husband's death. This is further supported by her weight loss, which can be a common physical manifestation of grief. The fact that her adult children urged her to seek help also indicates that they are concerned about her well-being during this difficult time. Therefore, the most appropriate analysis of this situation is that the patient is grieving the husband's death.

The patient may have feelings of powerlessness. This answer best demonstrates cultural awareness because it acknowledges the possibility that the patient's suspicious behavior and accusations of discrimination may stem from a sense of powerlessness. This understanding recognizes the potential impact of systemic racism and discrimination on individuals from marginalized communities, such as African Americans. It shows an awareness of the patient's cultural background and the potential influence it may have on their behavior and emotions.

The patient's statement about their energy becoming imbalanced suggests that they have a belief in the concept of energy imbalance, which is commonly associated with traditional Chinese medicine. In this context, it is likely that the patient may request to eat special foods as a way to treat the imbalance. Traditional Chinese medicine often uses dietary therapy as a means to restore balance in the body. Therefore, it is reasonable to assume that the patient may request this approach for treating their anxiety disorder.

The fourth-generation New England native who is an accountant is most likely to wish to engage actively in end-of-life planning because individuals who are familiar with the healthcare system and have a professional background are often more proactive in planning for their end-of-life care. Additionally, being a native of the region may also contribute to a greater sense of familiarity and comfort with discussing and making decisions about end-of-life care.

Consistently addressing patients by title and surname demonstrates respect and dignity towards the patients. It acknowledges their individuality and promotes a professional and respectful relationship between the nurse and the patient. This action shows that the nurse values the patient's identity and autonomy, which is essential in providing patient-centered care.

When a patient verbally refuses medication and the nurse gives the medication over the patient's objection, the nurse can be charged with battery. Battery refers to the intentional and unauthorized touching of another person without their consent. In this case, the nurse is administering medication against the patient's explicit refusal, which constitutes a violation of the patient's bodily autonomy and can be considered as a form of battery.

The nursing intervention that demonstrates false imprisonment is when a nurse escorts a patient down the hall and threatens to put them in seclusion if they do not stay in their room. False imprisonment refers to the unlawful restraint or confinement of a person against their will. In this case, the nurse is using the threat of seclusion to restrict the patient's movement, which is a violation of their rights. The other interventions described involve ensuring the safety of the patient and others without unlawfully restraining them.

The correct answer is to withhold the medication and confer with the healthcare provider. This is because prescribing a higher than usual dose of antidepressant to an elderly patient with major depression can increase the risk of adverse effects and side effects. Therefore, it is important for the nurse to withhold the medication and consult with the healthcare provider to ensure the safety and well-being of the patient. Consulting a drug reference may provide information about the usual geriatric dose, but in this case, the dose is already known to be higher than usual. Teaching the patient about side effects and encouraging increased oral fluids are not appropriate actions in this situation.

The answer provides a detailed and chronological account of the events that occurred leading up to the patient being placed in seclusion. It includes information about the patient's behavior, the administration of medication, and the patient's aggressive actions towards another patient. It also mentions the exact time when the patient was placed in seclusion and when the order was obtained from the physician. This documentation is comprehensive and provides a clear picture of the situation.

The patient's statement suggests a disturbance in their thought processes rather than a specific spiritual issue. The patient is expressing confusion and questioning why they are experiencing cancer despite living their life according to religious beliefs. This indicates a cognitive or mental disruption rather than a spiritual distress or dysfunction. Therefore, the nursing diagnosis of "Disturbed thought processes" is appropriate in this case.

This nursing documentation best meets the requirement for problem-oriented charting because it follows the SOAP (Subjective, Objective, Assessment, Plan) format. It includes the patient's subjective statement ("S: States 'I feel like I'm ready to blow up.'"), objective observations ("O: Pacing hall, mumbling to self."), assessment of the problem ("A: Auditory hallucinations."), plan of action ("P: Offer haloperidol 2 mg PO."), implementation of the plan ("I: Haloperidol 2 mg PO given at 0900."), and evaluation of the outcome ("E: Returned to lounge at 0930 and quietly watched TV."). This format allows for a comprehensive and organized documentation of the patient's problem and the interventions taken.

The nurse's next action should be to document the confusion and obtain other assessment data from the grandchild. This is important because it provides information about the patient's current mental status and helps gather additional information about the patient's condition from a reliable source. This will aid in the overall assessment and care planning for the patient.

The nurse's best reply is "Anything you say about feelings is private, but some things like suicidal thinking must be reported to the treatment team." This response acknowledges the adolescent's concern about privacy while also highlighting the importance of safety and well-being. It reassures the adolescent that their feelings will be kept confidential, but also emphasizes the need to involve the treatment team in situations that may pose a risk to their life.

The nurse is assessing the patient's understanding of abstract concepts. The saying "You can't judge a book by looking at the cover" is a metaphorical expression that means one cannot make accurate judgments or assumptions about something or someone based solely on their appearance. Understanding this saying requires the ability to think abstractly and grasp the deeper meaning behind the words. Therefore, the nurse is assessing the patient's abstraction skills.

The nurse should ask, "Are you having difficulty hearing when I speak?" because the patient's vague or unrelated answers, leaning forward, and frowning indicate that they may be experiencing hearing difficulties. By asking this question, the nurse can gather more information about the patient's hearing abilities and address any potential communication barriers that may be affecting the assessment process.

Milieu management refers to creating and maintaining a therapeutic environment for the patient. In this scenario, the nurse is taking the patient on a tour, explaining the rules, and providing information about the daily schedule. By doing so, the nurse is helping to establish a structured and supportive environment for the patient, which falls under the aspect of milieu management in care coordination.

The nurse should respond by assuring the patient that their information will be kept confidential, but also informing them that information may be shared with other staff members for the purpose of providing appropriate care. This response respects the patient's privacy and autonomy while also acknowledging the need for collaboration and communication within the healthcare team.

The desirable outcome for the initial stage of a nurse-patient relationship is for the patient to demonstrate behaviors that indicate rapport and trust with the nurse. This means that the patient feels comfortable and has established a positive connection with the nurse, which is crucial for effective communication and collaboration. Building rapport and trust helps create a supportive environment where the patient feels safe to express their concerns and work towards their healthcare goals. It also enhances the nurse's ability to provide quality care and promote the patient's overall well-being.

In the orientation phase of the nurse-patient relationship, the nurse and patient are getting to know each other and establishing trust. It is during this phase that the nurse should first address termination. By discussing termination early on, the nurse can prepare the patient for the eventual end of the therapeutic relationship and help them understand that it is a normal part of the process. This allows for a smoother transition and prevents any feelings of abandonment or confusion for the patient.

During the first session with a new patient, a nurse should introduce the matter of a contract because contracts spell out the participation and responsibilities of both parties. By establishing a clear agreement, the nurse and patient can have a mutual understanding of what is expected from each other in the therapeutic relationship. This helps to ensure that both parties are on the same page and can work together effectively towards the patient's goals.

The nurse's best response is to acknowledge the patient's progress and express gratitude for the recognition, but also to adhere to the agency's policies and procedures by declining the gift. This response shows professionalism and respect for the rules and boundaries set by the agency.

The nurse should recognize the patient's thoughtfulness and express appreciation by accepting the card. This action shows gratitude towards the patient and acknowledges their effort in making the card. It also helps to maintain a positive and supportive relationship between the nurse and the patient. Additionally, accepting the card does not violate any policies of the facility.

The correct answer is "I’d like to sit with you for a while to help you get comfortable talking to me." This response demonstrates offering self by showing a willingness to spend time with the patient and creating a safe and comfortable environment for them to open up and communicate. This approach promotes trust and establishes a therapeutic relationship between the nurse and the patient.