A nurse is admitted to a psychiatric unit and fails to follow her medication regimen. What does this behavior indicate?

Correct Answer: C

Rationale: The correct answer is C, 'Lack of health literacy.' The nurse's inability to follow the medication regimen suggests she may lack health literacy, meaning she may not fully understand how to manage her own health care. Choice A, 'Early cognitive impairment,' is not supported by the information provided in the question as there is no mention of cognitive decline. Choice B, 'Lack of motivation,' is less likely as the behavior is more indicative of a knowledge deficit rather than a lack of drive. Choice D, 'Worsening health state,' is also less likely as the behavior described does not directly imply a worsening health condition but rather a misunderstanding or lack of knowledge on managing health.

Correct Answer: D

Rationale: The evaluation phase of the nursing process is used to determine the degree of outcome achievement. It assesses whether the goals and outcomes set during the planning phase were met. Choice A is incorrect because it focuses on the worth of the intervention rather than the achievement of outcomes. Choice B is incorrect as it pertains to the assessment phase where problems are identified. Choice C is incorrect as it refers to the planning phase where the care plan is developed, not evaluated.

Correct Answer: C

Rationale: The psychomotor domain involves physical activity and motor skills, such as ambulation, making it the correct domain for this goal. Choices A, B, and D are incorrect: Affective domain focuses on emotions and attitudes, physical domain is not a recognized domain in Bloom's taxonomy, and cognitive domain pertains to knowledge and intellectual skills, none of which directly relate to the physical act of ambulation.

Correct Answer: C

Rationale: Inviting the patient to share concerns is an example of a culturally sensitive response as it acknowledges the patient's feelings and provides a safe space for them to express their discomfort. This approach shows respect for the patient's cultural beliefs and values by valuing their perspective. Choice A, asking why they feel this way, can be perceived as confrontational and may not encourage open communication. Choice B, explaining that the treatment is standard, dismisses the patient's feelings and does not address their discomfort. Choice D, offering alternative treatments, may be premature without fully understanding the patient's concerns first.

Correct Answer: B

Rationale: The correct first action when a client with schizophrenia reports hearing voices telling them to harm themselves is to ask the client what the voices are saying. This is important to assess the content of the hallucinations and determine if there is any immediate danger or suicidal intent. Administering antipsychotic medication without knowing the content of the voices or the level of danger could be inappropriate and potentially harmful. Distracting the client with another activity may not address the underlying issue of the hallucinations commanding harm. Calling the healthcare provider can be done after assessing the situation and gathering information from the client.