ATI RN
Behavioral Health Nursing Care Plans Questions
Question 1 of 5
A nurse is assessing a patient diagnosed with schizophrenia who is exhibiting disorganized speech. The patient states, 'I want to eat a chicken sandwich but the moon is yellow and all the words are backwards.' What is the most appropriate nursing intervention?
Correct Answer: A
Rationale: The most appropriate nursing intervention in this scenario is option A) Encourage the patient to focus on the present and engage in a simple conversation. This approach is grounded in therapeutic communication techniques for individuals with schizophrenia experiencing disorganized speech. By encouraging the patient to focus on the present and engage in a simple conversation, the nurse can help the patient reorient to reality and potentially decrease the disorganization in their speech. Option B) Redirect the conversation to focus on topics of interest to the patient may not be effective in this situation as it does not address the patient's disorganized speech directly or help them reorient to reality. Option C) Ask the patient to clarify their speech and provide feedback could potentially increase the patient's confusion and distress, as individuals with schizophrenia may struggle to clarify their disorganized thoughts and speech. Option D) Acknowledge the patient's speech and allow them to express their feelings, while important in building rapport and showing empathy, may not be the most beneficial intervention in this case where the patient's speech is disorganized and disconnected from reality. Educationally, it is crucial for nurses to understand the principles of therapeutic communication when working with patients with schizophrenia. By using techniques like focusing on the present and engaging in simple conversations, nurses can support patients in managing their symptoms and improving their communication skills.
Question 2 of 5
The adult child of a patient diagnosed with major depressive disorder asks, 'Do you think depression and physical illness are connected? Since my father's death, my mother has had shingles and the flu, but she's usually not one who gets sick.' Which answer by the nurse best reflects current knowledge?
Correct Answer: D
Rationale: The correct answer best explains the research. Research supports a link between negative emotions and/or prolonged stress and impaired immune system functioning. Activation of the immune system sends proinflammatory cytokines to the brain, and the brain in turn releases its own cytokines that signal the central nervous system to initiate myriad responses to stress. Prolonged stress suppresses the immune system and lowers resistance to illness. Although the adult child may be more aware of issues involving the mother, the pattern of illnesses described may be an increase from the mother's baseline.
Question 3 of 5
A patient tells the nurse, 'My doctor thinks my problems with stress relate to the negative way I think about things and suggested I learn new ways of thinking.' Which response by the nurse would support the recommendation?
Correct Answer: C
Rationale: Cognitive reframing focuses on recognizing and correcting maladaptive patterns of thinking that create stress or interfere with coping. Cognitive reframing involves recognizing the habit of thinking about a situation or issue in a fixed, irrational, and unquestioning manner. Helping the patient to recognize and reframe (reword) such thoughts so that they are realistic and accurate promotes coping and reduces stress. Thinking about being in calming circumstances is a form of guided imagery. Instruments that give feedback about bodily functions are used in biofeedback. Journaling is effective for helping to increase self-awareness. However, none of these last three interventions is likely to alter the patient's manner of thinking.
Question 4 of 5
A patient checks and rechecks electrical cords related to an obsessive thought that the house may burn down. The nurse and patient explore the likelihood of an actual fire. The patient states this event is not likely. This counseling demonstrates principles of
Correct Answer: D
Rationale: Cognitive restructuring involves the patient in testing automatic thoughts and drawing new conclusions. Desensitization involves graduated exposure to a feared object. Relaxation training teaches the patient to produce the opposite of the stress response. Flooding exposes the patient to a large amount of an undesirable stimulus in an effort to extinguish the anxiety response.
Question 5 of 5
A nurse manager had to terminate an employee. After the termination, the nurse manager had feelings of loss but then became supportive of the new manager by helping make the transition smooth and encouraging others. Which term best describes the nurse's response?
Correct Answer: A
Rationale: Altruism is the mechanism by which an individual deals with emotional conflict by meeting the needs of others and receiving gratification vicariously or from the responses of others. The nurse's reaction is conscious rather than unconscious. There is no evidence of suppression. Intellectualization is a process in which events are analyzed based on remote, cold facts and without passion, rather than incorporating feeling and emotion into the processing. Reaction formation is when unacceptable feelings or behaviors are controlled and kept out of awareness by developing the opposite behavior or emotion.