A nurse is working with a patient diagnosed with post-traumatic stress disorder (PTSD). Which of the following interventions would be most appropriate for this patient?

Correct Answer: D

Rationale: In the context of working with a patient diagnosed with post-traumatic stress disorder (PTSD), the most appropriate intervention is option D: Help the patient identify coping mechanisms and support systems. This is the correct choice because individuals with PTSD often benefit from learning and utilizing coping strategies to manage symptoms and navigate daily challenges. By helping the patient identify coping mechanisms tailored to their specific needs, the nurse empowers the individual to better regulate their emotions, reduce anxiety, and improve overall well-being. Option A, providing exposure therapy to confront trauma-related memories, may not be suitable initially as it can be overwhelming and retraumatizing for some individuals with PTSD. Gradual exposure under professional guidance may be more appropriate. Option B, encouraging the patient to avoid any discussions about the traumatic event, is not recommended as avoidance can perpetuate symptoms and hinder the healing process in the long run. It is important for individuals with PTSD to process and work through their experiences in a safe and supportive environment. Option C, administering sedative medications to manage anxiety during flashbacks, may be a short-term solution for acute distress but does not address the underlying issues associated with PTSD. Medications should be used in conjunction with therapy and coping strategies for optimal outcomes. In an educational context, understanding the rationale behind choosing appropriate interventions for individuals with PTSD is crucial for healthcare professionals. By prioritizing the identification of coping mechanisms and support systems, nurses can actively contribute to the holistic care and recovery of patients with PTSD, fostering resilience and empowerment in their journey towards healing.

Correct Answer: B

Rationale: The most appropriate intervention for a patient diagnosed with generalized anxiety disorder is to provide relaxation techniques such as deep breathing (Option B). This is because deep breathing exercises are a widely recognized evidence-based strategy for managing anxiety. Deep breathing helps activate the body's relaxation response, which can counter the physiological arousal associated with anxiety. Encouraging the patient to confront their fears directly (Option A) may actually exacerbate their anxiety and lead to increased distress. It is important not to push individuals with anxiety disorders into situations that may trigger overwhelming anxiety. Reassuring the patient that their anxiety is not warranted (Option C) is not helpful as it may invalidate their feelings and experiences. Anxiety disorders are real and valid mental health conditions that require understanding and appropriate interventions. Encouraging the patient to avoid stressful situations whenever possible (Option D) can contribute to the perpetuation of anxiety and limit the individual's ability to cope and adapt to challenging circumstances. Avoidance can lead to increased fear and avoidance behaviors, ultimately worsening the anxiety symptoms. In an educational context, it is crucial for healthcare providers, including nurses, to be well-versed in evidence-based interventions for anxiety disorders. By understanding the most effective strategies like deep breathing techniques, nurses can provide optimal care and support to patients with generalized anxiety disorder, promoting their overall well-being and mental health.

Correct Answer: B

Rationale: Assessing cognition involves determining a patient's judgment and decision making. In this case, the nurse would expect a response of 'Call my doctor' if the patient's cognition and judgment are intact. If the patient responds, 'I would stop eating' or 'I would just wait and see what happened,' the nurse would conclude that judgment is impaired. The other options refer to other aspects of the examination.

Correct Answer: A

Rationale: In this scenario, the correct answer is A) Nutritional deficiencies and electrolyte imbalances. This is the priority concern for the nurse because individuals with bulimia nervosa often engage in binge eating followed by purging behaviors like self-induced vomiting, which can lead to severe consequences such as electrolyte imbalances (e.g., hypokalemia) and nutritional deficiencies (e.g., low levels of vitamins and minerals). These complications can have serious implications on the patient's physical health, potentially leading to cardiac arrhythmias, muscle weakness, and other life-threatening conditions. Option B) Impulsivity and emotional dysregulation, while important factors in understanding and treating bulimia nervosa, are not the immediate priority in this case. Addressing nutritional deficiencies and electrolyte imbalances takes precedence due to their acute and potentially life-threatening nature. Option C) Distorted body image and low self-esteem are common psychosocial issues in individuals with bulimia nervosa but do not pose an immediate threat to the patient's physical health compared to the risks associated with electrolyte imbalances and nutritional deficiencies. Option D) Excessive exercise and weight loss are more commonly associated with anorexia nervosa rather than bulimia nervosa. While these behaviors can co-occur in some cases, they are not the primary concern in a patient presenting with binge eating and purging behaviors. Educationally, it is crucial for nurses and healthcare providers to prioritize the management of acute physical health concerns in individuals with eating disorders to prevent serious complications. Understanding the hierarchy of concerns allows for appropriate triaging and intervention to address the most critical issues first, ensuring the safety and well-being of the patient.

Correct Answer: B

Rationale: In behavioral nursing, after formulating nursing diagnoses for a new patient, the nurse's next action should be determining the goals and outcome criteria (Option B). This step is crucial as it sets the direction for the plan of care. By establishing clear goals and outcome criteria, the nurse can develop a targeted and effective care plan that addresses the patient's specific needs and helps in evaluating the success of the interventions over time. Option A, designing interventions, is premature without clearly defined goals. Without specific goals, interventions may not be aligned with the desired outcomes, leading to ineffective care. Option C, implementing the nursing plan of care, should only occur after goals are established to ensure that interventions are purposeful and tailored to the patient's needs. Option D, completing the spiritual assessment, is important but typically falls within the assessment phase and may not be the immediate next step after formulating nursing diagnoses. It is essential for holistic care but may not directly follow the formulation of nursing diagnoses in the care planning process. Understanding the sequential nature of the nursing process is essential for providing efficient and effective care. By prioritizing goal setting after formulating nursing diagnoses, nurses can ensure that their interventions are focused, measurable, and aligned with the patient's needs, ultimately leading to better patient outcomes.