Choice A Reason:

Monitoring nutrition and self-care is correct. Ensuring patients are maintaining proper nutrition and engaging in self-care activities is an essential part of psychiatric nursing care.

Choice B Reason:

Providing round-the-clock supervision is correct. In an inpatient psychiatric unit, especially for patients at risk of harm to themselves or others, providing continuous supervision is often necessary to ensure safety.

Choice C Reason:

Offering structured socialization activities is correct. Structured socialization activities can contribute to patients' well-being and help create a therapeutic and supportive environment.

Choice D Reason:

Establishing a long-term therapeutic relationship is incorrect. While building therapeutic relationships is important, establishing a "long-term" therapeutic relationship might be more applicable in outpatient or community settings. In an inpatient unit, the focus may be on immediate care needs and stabilization.

Choice E Reason:

Assisting patients in self-assessment is correct. Helping patients in self-assessment is a crucial aspect of psychiatric nursing, as it fosters self-awareness and empowers individuals to actively participate in their treatment.

Choice A Reason:

"If it weren't for you and the hours we've spent talking, I don't think I would be on my way to getting my anxiety under control." While this statement acknowledges the importance of the nurse-patient relationship in helping with anxiety, it might imply a somewhat dependent stance. The ideal therapeutic relationship encourages patients to gain skills and tools to manage their issues independently.

Choice B Reason:

"I appreciate the time you spent with me. I have a better understanding of what I can do to manage my problem." This statement reflects the patient's acknowledgment of the nurse's support and guidance, resulting in a positive impact on the patient's understanding and ability to manage their concerns. It emphasizes the constructive nature of the nurse-patient relationship and the effectiveness of the interactions in addressing the patient's needs.

Choice C Reason:

"I really need to talk with you. You always give me good advice about how to address my anger issues." While seeking support and advice from the nurse is positive, the emphasis on always receiving good advice might suggest a more directive approach rather than collaborative exploration and problem-solving, which is often a goal in therapeutic relationships.

Choice D Reason:

"You've been kind to me when I was at a low point. Knowing you've had low points too was such a help. “While mutual understanding and empathy are crucial in the nurse-patient relationship, the statement may focus more on the nurse's experiences rather than the patient's progress or understanding. The primary focus should be on the patient's needs and growth.

Choice A Reason:

"It might help you feel better if you talk about it." While encouraging communication is generally good, the client has clearly expressed a desire not to talk at the moment. Pressuring them to talk may not be beneficial.

Choice B Reason:

"I'll just sit here with you for a few minutes then." This response acknowledges the client's need for solitude while showing a willingness to provide presence and support. It respects the client's autonomy and allows them to lead the interaction.

Choice C Reason:

"I understand; I've felt like that before, too." While expressing empathy can be helpful, it's important not to overshadow the client's experience by sharing personal feelings at this moment.

Choice D Reason:

"Why are you feeling so down?" This question may feel intrusive and may not be well-received by the client, especially when they've indicated a preference not to talk. It's important to approach the conversation with sensitivity and respect for the client's boundaries.

Choice A Reason:

To provide support for the patient is not appropriate. While providing support is important in therapeutic communication, the nurse's statement is more focused on bringing attention to an inconsistency rather than offering direct emotional support.

Choice B Reason:

To redirect the patient to an important idea is not appropriate. The nurse's statement is not aimed at redirecting the patient to a specific idea. Instead, it's about highlighting a potential incongruence between the patient's verbal and nonverbal expressions.

Choice C Reason:

To provide a suggestion for coping strategies is not appropriate. The nurse's statement is not directly offering suggestions for coping strategies. It is more focused on helping the patient recognize and explore the discrepancy in their expressed emotions.

Choice D Reasons:

To bring inconsistencies into awareness is appropriate. This therapeutic communication technique is aimed at helping the patient recognize and explore any inconsistencies between their verbal and nonverbal expressions. By pointing out the discrepancy between the patient's statement of feeling sad and the observed behavior of smiling, the nurse encourages the patient to reflect on and explore their emotions more deeply. This can contribute to increased self-awareness and a better understanding of the patient's emotional state.

Choice A Reason:

The coping skills (Choice A) may be observed and assessed as part of the broader clinical picture, but they are not typically specific components of a formal Mental Status Examination.

Choice B Reason:

Ability to perform calculations. This assesses the client's cognitive abilities, specifically related to mathematical reasoning and problem-solving.

Choice C Reason:

Recall ability. Assessing recall ability helps evaluate the client's short-term memory, which can be impaired in individuals with dementia.

Choice D Reason:

Long-term memory. Evaluating long-term memory provides insights into the client's ability to recall information from the distant past, which is another aspect of cognitive function.

Choice E Reason:

Level of orientation. Assessing orientation to time, place, and person is crucial in understanding the client's awareness of their surroundings and current circumstances, which can be affected in dementia.

Choice A Reason:

“I live too far from art and history museums to visit them as often as I would like. “This pertains more to self-actualization and leisure activities, which are higher-level needs.

Choice B Reason:

"Four robberies and three assaults occurred in my neighborhood in the past month. “This statement addresses safety concerns, which fall under the second level of Maslow's hierarchy. Ensuring safety is a fundamental need that takes priority before addressing social or esteem needs.

Choice C Reason:

"I feel so alone. I wish I had someone special in my life." This addresses the need for belonging and social connection, which is a higher-level need compared to safety.

Choice D Reason:

"I did not do a good job on the project my supervisor assigned." This relates to self-esteem and job performance, which are higher-level needs.

Choice A Reason:

Encourages staff to provide frequent negative feedback to patient is incorrect. A therapeutic milieu typically focuses on positive reinforcement and constructive feedback to support patients' growth and development.

Choice B Reason:

Enforces rules and behavioral limits flexibly is incorrect. While establishing rules and limits is important for maintaining safety, flexibility in enforcing them allows for individualized care and consideration of the patient's unique needs.

Choice C Reason:

Permits additional privileges for voluntary admitted patients is incorrect. Additional privileges may be granted based on the patient's progress and participation in their treatment. However, it should be done thoughtfully and as part of a therapeutic plan rather than as a blanket permission for all voluntary admitted patients.

Choice D Reason:

Provides patients a sense of security and comfort is correct. A therapeutic milieu refers to the therapeutic environment or surroundings in a psychiatric setting that promotes the patient's well-being, safety, and recovery. This environment should be supportive, safe, and conducive to healing. Providing patients with a sense of security and comfort is essential for their overall well-being and progress in treatment.

Choice A Reason:

Differentiation is incorrect. Differentiation refers to the ability of family members to maintain their individuality while remaining emotionally connected. It is not directly related to involving a third person in conflicts.

Choice B Reason:

Scapegoating is incorrect. Scapegoating involves blaming one family member for the family's problems. While this can be a dysfunctional family dynamic, it is not specifically about involving a third person in conflicts.

Choice C Reason:

Double Binding is incorrect. Double binding involves conflicting messages that create a no-win situation for the recipient. It does not specifically involve the inclusion of a third person in conflicts as observed in the given scenario.

Choice D Reason:

Triangulation is correct. Triangulation in family systems therapy occurs when a third person, often a child, is involved in the conflicts between two other family members. In this scenario, Kate is venting her frustrations to her younger son, which creates a triangle or three-person dynamic in the family system. Triangulation can serve as a way for family members to stabilize their relationships by shifting the focus or tension onto a third party.

Choice A Reason:

"Why do you think you might have cancer when your diagnosis is a benign condition?” This response may come across as dismissive and could make the client feel unheard. It does not acknowledge the client's concerns and may discourage open communication.

Choice B Reason:

"I'm hearing that you are concerned that might turn out that you have cancer.” This response demonstrates active listening and acknowledges the client's expressed concern. It encourages the client to share their feelings and provides an opportunity for further discussion. Option B shows empathy and supports the client's emotional needs during a stressful time.

Choice C Reason:

"I'm looking at your chart here and I don't see any reason for you to worry about that.” This response focuses on the medical chart and might minimize the client's emotional concerns. It does not address the client's feelings and may create a sense of invalidation.

Choice D Reason:

"I think that's something you need to discuss with your provider.” While it directs the client to the provider, it doesn't acknowledge the client's emotions or provide immediate support. It may seem like a deflection rather than an empathetic response.

Choice A Reason:

"Now that we've discussed your reasons for being here and how often we will meet, I'd like to talk about what we will do at the time of your discharge." This option seems to introduce the topic of termination prematurely, especially if the client's issues and goals haven't been adequately addressed yet.

Choice B Reason:

"You are being discharged today, so I'd like to bring up the subject of termination, which includes discussing your time here and summarizing what coping skills you have attained."This option presents termination at the time of discharge without prior discussion or collaboration with the client.

Choice C Reason:

"Now that we are working on your problem-solving skills and the behaviors you'd like to change, I'd like to bring up the issue of termination." In therapeutic relationships, termination is an essential phase that involves discussing the ending of the relationship and summarizing the progress made. Bringing up the topic of termination when actively working on the client's goals and issues is appropriate. It allows for a collaborative discussion about the achievements, future plans, and coping strategies that the client has developed during the therapeutic process.

Choice D Reason:

"I haven't met my new patient yet, but am working through my feelings of anxiety in dealing with a parent who wanted to kill herself." This statement is not related to the discussion of termination in the ongoing nurse-patient relationship.

Choice A Reason:

In the orientation phase is false. The orientation phase is focused on establishing rapport, building trust, and identifying the patient's needs and goals. It is too early to discuss termination during this phase.

Choice B Reason:

On the working phase is false. The working phase involves active problem-solving, goal attainment, and skill development. While progress is being made, it is not the appropriate time to introduce the topic of termination.

Choice C Reason:

When the patient brings up the topic is false. While it's important to be responsive to the patient's concerns, addressing the issue of termination solely based on the patient's initiation may not provide a comprehensive and planned discussion. The nurse should guide the conversation about termination at the appropriate time, considering the progress made in therapy.

Choice D Reason:

The termination phase is the final phase of the therapeutic relationship, and it involves discussing and planning for the conclusion of the therapeutic alliance. It provides an opportunity for the nurse and patient to reflect on the progress made, revisit goals, and discuss strategies for maintaining gains after the conclusion of the formal therapeutic relationship.

Choice A Reason:

Diffuse is correct. In a diffuse or permeable family boundary, there is a lack of clear separation between family members. Decisions and responsibilities may be shared extensively, and individual autonomy is limited. The patient's behavior of consulting with family members before making treatment decisions suggests a diffuse boundary where decision-making involves significant input from various family members.

Choice B Reason:

Clear is incorrect. - In a clear or rigid boundary, there is a distinct separation between family members, and individual autonomy is highly emphasized. The described behavior does not align with a clear boundary.

Choice C Reason:

Differentiation is incorrect. Differentiation refers to the ability of family members to maintain their individuality while remaining emotionally connected. The behavior described is more indicative of a diffuse boundary than a differentiation issue.

Choice D Reason:

Rigid is incorrect. A rigid boundary is characterized by strict rules and limited flexibility. The described behavior does not align with a rigid boundary where decision-making might be more centralized and less consultative.

He has been prescribed Fluphenazine decanoate 87.5 mg intramuscularly every 3 weeks to treat his schizophrenia. The nurse checks the medication order and the vial label. The vial contains Fluphenazine decanoate 25 mg per milliliter. To calculate the amount of medication to administer, the nurse uses the formula:

dose ordered / dose available = mL to administer

Substituting the values, the nurse gets:

87.5 mg / 25 mg/ml = 3.5 ml

Therefore, the nurse will administer 3.5 milliliters of Fluphenazine decanoate for this dose.

Choice A Reason:

Wife/mother is incorrect. The wife/mother expresses that she is not skillful in conflict resolution, but her concerns are related to her own abilities rather than exhibiting specific problematic behaviors that are disruptive or distressing to the family system.

Choice B Reason:

Daughter is correct. The daughter, who is rebellious and in academic trouble, is most likely to be listed as the "identified patient" because her behavior is presenting visible challenges and concerns. In family systems therapy, addressing and understanding the dynamics surrounding the identified patient can provide insights into the broader family issues and interactions.

Choice C Reason:

Son is incorrect. The son is conflicted about where to attend college, which is a common developmental decision. While it may cause some family stress, it doesn't necessarily indicate the presence of disruptive or problematic behavior warranting the label of "identified patient."

Choice D Reason:

Husband/father is incorrect. The husband/father is skeptical of the idea that talking can be helpful, but skepticism or reluctance to engage in therapy does not necessarily make him the identified patient. His behavior doesn't present as a disruptive symptom within the family.

Choice A Reason:

Countertransference is incorrect. Countertransference involves the therapist's emotional reactions to the client based on the therapist's unresolved issues or feelings. It is not about viewing the client positively.

Choice B Reason:

Genuineness is incorrect. Genuineness, also known as congruence, is the therapist's ability to be authentic and transparent in the therapeutic relationship. While it contributes to a positive therapeutic environment, it is not specifically about viewing the client's worth and strengths.

Choice C Reason:

Positive Regard is correct. Positive regard, as proposed by Carl Rogers in person-centered therapy, refers to the therapist's genuine acceptance and caring for the client. It involves recognizing the client's worth, strengths, and potential for growth. Providing positive regard creates a supportive and nonjudgmental environment that facilitates the client's self-exploration and personal development.

Choice D Reason:

Empathy is incorrect. Empathy involves understanding and sharing the feelings of the client. While it contributes to a positive therapeutic relationship, it does not necessarily focus on viewing the client as having strengths and achievement potential.

Choice A Reason:

Facing reality and developing standards for responsible behavior is inappropriate. This goal aligns more with reality therapy or choice theory, which focuses on helping individuals take responsibility for their behavior and make choices that lead to responsible actions.

Choice B Reason:

Examining irrational beliefs and eliminating self-defeating behaviors is appropriate. Beck's cognitive-behavioral therapy (CBT) is based on the premise that thoughts influence feelings and behaviors. The goal of CBT is to identify and change irrational or distorted thoughts that contribute to negative emotions and behaviors. This process involves examining irrational beliefs and challenging cognitive distortions to promote more realistic and adaptive thinking.

Choice C Reason:

Developing satisfactory relationships, maturity, and relative freedom from anxiety is inappropriate. This goal may align with psychodynamic or humanistic approaches that emphasize personal growth, self-awareness, and improvement in relationships.

Choice D Reason:

Reducing body tension through biofeedback training is inappropriate. This goal is more aligned with behavioral approaches that use techniques like biofeedback to address physiological symptoms.

Choice A Reason:

Triage and stabilization of the acute symptoms are a priority describes the focus of psychiatric emergency care. Psychiatric emergency care focuses on the rapid assessment, triage, and stabilization of individuals experiencing acute psychiatric symptoms or crises. The primary goal is to address immediate safety concerns, stabilize the individual's condition, and determine the appropriate level of care or intervention. This may involve crisis intervention, brief assessment, and referral to appropriate services.

Choice B Reason:

A nurse visits one to three times a week to assess for extreme agitation does not describe the focus of psychiatric emergency care. This describes a more routine or outpatient assessment schedule rather than the urgent and immediate focus of psychiatric emergency care.

Choice C Reason:

Overnight short-term observations are 1 to 3 days in duration does not describe the focus of psychiatric emergency care. This refers to a short-term observation period, which might occur in various psychiatric settings, but it does not specifically address the urgency of psychiatric emergencies.

Choice D Reason:

Antipsychotic medications are administered does not describe the focus of psychiatric emergency care. Administering antipsychotic medications is a treatment approach that may be part of the overall psychiatric care plan, but it does not specifically capture the immediate triage and stabilization focus of psychiatric emergency care.

Choice A Reason:

"Your mother will be fine. You shouldn't work so much." This response dismisses the son's feelings and does not address his sense of responsibility.

Choice B Reason:

"So, it seems that you feel responsible for what happened to your mother." This response is more direct in acknowledging the son's feelings but might be perceived as judgmental or clinical. It's important to convey understanding and empathy.

Choice C Reason:

"Why do you blame yourself? You could not have prevented the stroke." While this response is accurate, it may come across as somewhat confrontational and might not be as empathetic as option D. It focuses on the rational aspect without acknowledging the emotional component of the son's feelings.

Choice D Reason:

"You are not responsible for your mother's stroke, but many people in your situation feel this way." This response acknowledges the son's feelings of guilt while also offering reassurance that he is not to blame for his mother's stroke. It normalizes the son's emotions by mentioning that many people in similar situations may experience similar feelings of guilt or responsibility. This response is empathetic and validates the son's emotions without placing blame.

Choice A Reason:

A patient who states "I have no one who cares about me. "This statement relates more to the need for belonging and love, which is a lower level on Maslow's hierarchy.

Choice B Reason:

A patient who states "I have never met my career goals." This statement relates to self-esteem and self-actualization needs, which are higher-level needs in Maslow's hierarchy.

Choice C Reason:

A patient who exhibits hostile and angry behaviors is correct. Maslow's hierarchy of needs places safety and security needs above other needs. The patient exhibiting hostile and angry behaviors may pose a threat to their own safety, the safety of others, or the overall therapeutic environment. Addressing safety concerns and de-escalating aggressive behaviors takes precedence in this situation.

Choice D Reason:

A patient upset that his family can only visit during visiting hours. This situation is related to social needs and may not be as immediate a concern as the hostile and angry behaviors described in option C.

Choice A Reason:

Demonstrate genuineness when communicating is correct. Establishing therapeutic relationships in mental health nursing involves demonstrating genuineness, empathy, and trustworthiness in communication. Genuineness involves being authentic, sincere, and honest in interactions with clients. It fosters a sense of trust and connection, which is essential for the therapeutic relationship.

Choice B Reason:

Focusing on the words of the clients is incorrect. While it's important to listen actively to clients, effective communication goes beyond just focusing on words. Nonverbal cues, emotions, and the overall context of communication are also crucial.

Choice C Reason:

Providing sympathy during interactions is incorrect. Sympathy involves feeling sorry for someone, which may not always be helpful in a therapeutic relationship. Empathy, where the nurse understands and shares the client's feelings, is generally more therapeutic.

Choice D Reason:

Controlling the pace of establishing the nurse-client relationships is incorrect. The establishment of therapeutic relationships is a collaborative process, and attempting to control the pace might hinder the development of trust. It's important to be responsive to the client's needs and preferences.

Choice A Reason:

"Your provider is very knowledgeable, if he prescribes chemotherapy, it's the best treatment for you.” This response may be perceived as dismissive of the client's concerns and preferences. It is important to acknowledge and explore the client's perspective rather than making assumptions.

Choice B Reason:

"Using nontraditional treatments is not a good deal, rather you avoid that route.” This response is directive and may be seen as judgmental. It does not invite the client to share their concerns openly and may hinder effective communication.

Choice C Reason:

"Tell me more about your concerns about taking chemotherapy.” This response encourages open communication and demonstrates active listening. It allows the nurse to understand the client's concerns and preferences regarding chemotherapy. This approach supports a collaborative decision-making process, respects the client's autonomy, and helps build trust in the nurse-client relationship.

Choice D Reason:

"A lot of people think nontraditional treatments will work, they end up regretting that choice. “This response introduces a potentially guilt-inducing statement and may create a negative atmosphere. It does not encourage the client to express their thoughts and concerns openly.

Choice A Reason:

Formulating a nursing diagnosis is incorrect. This occurs after a comprehensive assessment of the patient's needs, and it helps guide the planning and implementation of nursing care.

Choice B Reason:

Planning for continued care is incorrect. Once the nursing diagnosis is formulated, the nurse can develop a plan of care, including interventions and goals for the patient.

Choice C Reason:

Promoting patient's insight is incorrect. This is a part of the ongoing therapeutic process and involves helping the patient gain self-awareness and understanding of their thoughts, feelings, and behaviors. It typically occurs after the initial assessment and planning.

Choice D Reason:

Examining personal biases is correct. In the nurse-patient relationship, examining personal biases is a foundational and essential step that should happen first. It involves the nurse being self-aware and acknowledging any personal biases or prejudices that might affect the therapeutic relationship. Recognizing and addressing personal biases is crucial for providing unbiased and patient-centered care.

Choice A Reason:

"I’m so sad and I feel I haven't accomplished much in my life." This statement may relate more to feelings of despair and a sense of unfulfilled purpose, which could be associated with Erikson's stage of Integrity vs. Despair (late adulthood).

Choice B Reason:

"I’m so anxious, can't seem to trust anyone. “This statement may indicate difficulties with trust and may be more aligned with Erikson's stage of Trust vs. Mistrust (infancy).

Choice C Reason:

"I'm so tired after work that I just want to watch TV and be alone. “This statement may reflect fatigue or a desire for solitude and may not directly represent the identity development struggles associated with Erikson's Identity vs. Role Confusion stage.

Choice D Reason:

"I'm so confused about what my goals are.” Erikson's phase of Identity vs. Role Confusion occurs during adolescence, and individuals in this stage are exploring and forming their own identity. The statement "I'm so confused about what my goals are" suggests a struggle with establishing a clear sense of identity and future direction, which is characteristic of the challenges faced during this developmental stage.

Choice A Reason:

Helping the patient to identify personal strengths and limitations is appropriate. This helps build a positive foundation for the therapeutic relationship by focusing on the patient's strengths and empowering them in the process.

Choice B Reason:

Explore, in depth, the problems faced by the patient is inappropriate. While understanding the patient's concerns is important, diving too deeply into problems at the beginning might be overwhelming. It's often more effective to gradually explore issues as trust is established.

Choice C Reason:

Clarifying how long the relationship will last is inappropriate. Specifying the duration of the therapeutic relationship may create anxiety for the patient. Therapeutic relationships are often open-ended, and discussing termination should occur at an appropriate time in the future.

Choice D Reason:

Reviewing the terms of confidentiality is appropriate. Clarifying the terms of confidentiality is important to establish trust and inform the patient about the boundaries of the therapeutic relationship.

Choice E Reason:

Helping the patient prioritize and revise ineffective coping behaviors is appropriate. Collaboratively working with the patient to identify and address ineffective coping behaviors is a therapeutic intervention that supports the patient in their journey toward improved mental health.

Choice A Reason:

Technical expert is correct. In Peplau's Interpersonal Relations in Nursing theory, the emphasis is on the interpersonal and psychosocial aspects of nursing. While technical expertise is crucial in nursing practice, it is not specifically identified as a distinct role according to Peplau. The theory focuses more on the nurse's role in facilitating the patient's growth and development through the therapeutic relationship.

Choice B Reason:

Resource is incorrect. Peplau identified the nurse as a resource, emphasizing the nurse's role in providing information, support, and guidance to the patient. This aligns with the concept of the nurse as a source of knowledge and assistance for the patient.

Choice C Reason:

Surrogate is incorrect. The surrogate role in Peplau's theory reflects the nurse's ability to act on behalf of the patient, representing their best interests, especially in situations where the patient may be unable to advocate for themselves. The nurse serves as a substitute or stand-in for the patient in certain circumstances.

Choice D Reason:

Guardian is incorrect. The guardian role in Peplau's theory emphasizes the nurse's responsibility to protect the patient's rights and advocate for their well-being. The nurse acts as a guardian of the patient's interests, ensuring they receive appropriate care and support.