A nurse documents: Patient is mute despite repeated efforts to elicit speech. Makes no eye contact. Inattentive to staff. Gazes off to the side or looks upward rather than at speaker. Which nursing diagnosis should be considered?

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Behavioral Questions for Nurse Questions

Question 1 of 5

A nurse documents: Patient is mute despite repeated efforts to elicit speech. Makes no eye contact. Inattentive to staff. Gazes off to the side or looks upward rather than at speaker. Which nursing diagnosis should be considered?

Correct Answer: D

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Question 2 of 5

Which of the following are the types of roles that are usually included when assessing roles and relationships? Select all that apply.

Correct Answer: B

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Question 3 of 5

Sexuality and self-harm behaviors are often difficult areas for nurses to assess. An effective way for nurses to deal with this discomfort includes

Correct Answer: A

Rationale: Two areas that may be uncomfortable or difficult for the nurse to assess are sexuality and self-harm behaviors. The beginning nurse may feel uncomfortable, as if prying into personal matters, when asking questions about a client's intimate relationships and behavior and any self-harm behaviors or thoughts of suicide. Asking such questions, however, is essential to obtaining a thorough and complete assessment. The nurse needs to remember that it may be uncomfortable for the client to discuss these topics as well.

Question 4 of 5

A client who had agreed to be hospitalized for depression problems has decided that now she wants to leave the hospital. The mental health staff caring for her realizes that at present she can legally

Correct Answer: C

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Question 5 of 5

Placing a client in restraints before using other methods of intervention violates which of the client's rights?

Correct Answer: D

Rationale: The least restrictive environment means that the client must be free of restraint or seclusion unless it is necessary. Less restrictive treatments must be tried and found to be ineffective before more restrictive measures can be used. It is not necessary for the client to provide informed consent for restraints to be used when appropriate. A client may not refuse restraints if they are to be used when appropriate.

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