ATI RN
Behavioral Health Nursing Care Plans Questions
Question 1 of 5
A nurse is working with a patient diagnosed with schizophrenia who is experiencing disorganized thinking. Which of the following is an example of disorganized thinking?
Correct Answer: B
Rationale: The correct answer is B) The patient's speech is fragmented and difficult to understand. Disorganized thinking is a hallmark symptom of schizophrenia, characterized by incoherent and fragmented speech patterns that make it challenging to follow the patient's thoughts. This can include rapid shifts in topics, tangential responses, or even word salad where words are strung together without logical connection. Option A is incorrect because speaking in a logical, coherent manner with clear thoughts does not demonstrate disorganized thinking, which is a specific symptom of schizophrenia. Option C describes delusional thinking, which is a different symptom associated with schizophrenia but not synonymous with disorganized thinking. Option D mentions well-organized thoughts with concentration difficulties, which is more indicative of attention deficits rather than disorganized thinking. In an educational context, understanding the nuances of symptoms like disorganized thinking in schizophrenia is crucial for nurses to provide appropriate care and support for patients. Recognizing these symptoms helps in developing effective nursing care plans tailored to the individual's needs, promoting better outcomes and quality of life for patients with schizophrenia.
Question 2 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 3 of 5
Documentation in a patient's chart shows, 'Throughout a 5-minute interaction, patient fidgeted and tapped left foot, periodically covered face with hands, and looked under chair while stating, 'I enjoy spending time with you.' Which analysis is most accurate?
Correct Answer: C
Rationale: When a verbal message is not reinforced with nonverbal behavior, the message is confusing and incongruent. It is inaccurate to say that the patient is giving positive feedback about the nurse's communication techniques. The concept of a cultural filter is not relevant to the situation because a cultural filter determines what we will pay attention to and what we will ignore. Data are insufficient to draw the conclusion that the patient is demonstrating psychotic behaviors.
Question 4 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 5 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.