Exam 9: Working With an Individual Patient

As the nurse plans care for a newly admitted patient, identification of dysfunctional behaviors will provide the focus for which component of the nursing process?

A newly admitted patient tells the nurse, "The voices are bothering me." What should be the nurse's initial intervention?

Objective data obtained from family in an initial assessment of a patient are of particular value when which situation exists?

What activity would be involved in achieving an appropriate short-term goal for a patient diagnosed with situational low self-esteem?

A patient with a history of self-mutilation says to the nurse, "I want to stop hurting myself." What is the initial step of the problem-solving process to be taken toward resolution of a patient's identified problem?

A patient tells the nurse, "I was raped a month ago. Since then I've felt anxious and have been unable to talk normally to my husband. I've had frequent thoughts about cutting my wrists." What is the priority nursing concern regarding this patient?

Which nursing intervention will initially be most helpful for trust building with a suspicious patient?

A nurse tells a patient, "I know how you feel. My spouse can be very insensitive too. I am also considering divorce." What behavior is the nurse demonstrating?

A patient playing pool with another patient throws down the pool cue and begins swearing. What action should the nurse implement initially to address this situation?

What fact about a particular patient will have the greatest impact on nurse-patient collaboration?

What statement made by a nursing is most helpful when moving into the working stage of a therapeutic relationship with a patient?

A nurse and patient who developed a therapeutic relationship enter into the final phase of their relationship as the patient prepares for discharge. What is an important nursing intervention for this stage of the relationship?

A psychotic patient tells the nurse, "Get away from me or I'll hit you. You're sucking the thoughts out of my head." To best de-escalate the situation, what intervention should the nurse implement?

A nurse plans to teach a group of patients the basics of the change process. How should the elements be sequenced for the presentation? (Select all that apply.)

Which statement is most therapeutic when working with a patient believed to be experiencing emotional pain?

During a mental status examination (MSE) a patient says, "I am a special messenger sent to provide the world a cure for cancer." The patient's statement indicates the presence of what form of dysfunctional thought content?

A student states, "I do not see the value of process recordings." The response to this concern should be based on what information related to process recording?

Which statement by a patient would the nurse interpret as willingness to collaborate in the nurse-patient relationship?

Which goal statement is most appropriate for a newly admitted patient currently in the orientation stage of the nurse-patient relationship?

A patient says, "I went out drinking only one time last week. At least I'm trying to change." The nurse responds, "I appreciate your effort, but you agreed to abstain from alcohol completely." The nurse's response demonstrates the ability to manage what potential patient centered problem?