A nurse prepares to assess a new patient who moved to the United States from Central America 3 years ago. After introductions, what is the nurse's next comment?

Correct Answer: D

Rationale: The nurse should determine whether a translator is needed by first assessing the patient for language barriers. Accuracy of the assessment depends on the ability to communicate in a language that is familiar to the patient. Family members are not always reliable translators. An interpreter may change the patient's responses; a translator is a better resource.

Correct Answer: D

Rationale: Offering self' is a technique that should be used in the orientation phase of the nurse-patient relationship. Sitting with the patient, an example of 'offering self,' helps to build trust and convey that the nurse cares about the patient. Two incorrect responses are ineffective and nontherapeutic. The other incorrect response is therapeutic but is an example of 'offering hope.'

Correct Answer: D

Rationale: The correct answer is D) belongs to a culture in which dramatic body language is the norm. This choice is supported by the patient's Puerto Rican American background, where expressive body language is a common way of communicating emotional distress. Understanding the patient's cultural context is crucial in providing appropriate care and communication. Option A) suggesting a histrionic personality disorder is incorrect as it pathologizes the behavior without considering cultural differences. Option B) assuming the behavior is sexually appealing is a biased and inappropriate interpretation. Option C) assuming the patient wishes to impress staff overlooks the cultural aspect and may lead to miscommunication and misunderstanding. In an educational context, this question highlights the importance of cultural competence in healthcare. Nurses need to be aware of and respect diverse cultural expressions of emotions to provide effective and sensitive care. Understanding cultural norms can enhance communication, build trust with patients, and ultimately improve health outcomes.

Correct Answer: C

Rationale: In this scenario, the most appropriate nursing diagnosis for a patient diagnosed with generalized anxiety disorder who expresses worrying about everything, even things beyond their control, is option C) Anxiety. The correct answer, "Anxiety," is the most suitable nursing diagnosis because the patient's statement directly aligns with the defining characteristics of generalized anxiety disorder, which include excessive worry and inability to control that worry. By selecting this option, the nurse acknowledges the patient's condition and can plan interventions to address the anxiety symptoms effectively. Option A) Imbalanced nutrition: Less than body requirements, is incorrect as there are no indicators in the scenario that suggest issues with nutrition intake. Option B) Ineffective coping is not the most appropriate choice in this case because the patient is not displaying maladaptive coping mechanisms but rather expressing excessive worry, which aligns more closely with symptoms of anxiety disorder. Option D) Risk for self-directed violence is also not the most suitable option as there is no evidence in the scenario to suggest that the patient is at an immediate risk for self-harm. In an educational context, understanding how to accurately assess and diagnose patients with mental health conditions is crucial for nurses to provide effective care. By selecting the correct nursing diagnosis, nurses can tailor their interventions to address the specific needs of the patient and promote positive outcomes in their mental health treatment.

Correct Answer: B

Rationale: In this scenario, the most appropriate intervention for the nurse to prioritize is option B: Set firm limits on impulsive behaviors and provide clear boundaries. This is because individuals with bipolar disorder often struggle with impulsivity, and setting clear boundaries helps establish structure and safety for the patient. By setting limits, the nurse can help prevent harmful consequences of impulsive actions and guide the patient towards more controlled decision-making. Option A, encouraging the patient to limit social interactions, may not address the core issue of impulsive behaviors associated with bipolar disorder. Social isolation can also have negative effects on mental health, so this intervention could potentially worsen the patient's condition. Option C, providing positive reinforcement for responsible decisions, is important in behavioral interventions. However, in this case, the impulsive behaviors of excessive spending and poor judgment require more immediate and direct intervention through setting limits rather than solely relying on positive reinforcement. Option D, encouraging group therapy and social activities, can be beneficial for overall mental health support. However, in the context of managing impulsive behaviors, establishing clear boundaries and limits should take precedence to ensure the patient's safety and well-being. In an educational context, understanding the rationale behind prioritizing interventions in managing behavioral symptoms of mental health disorders is crucial for nurses and healthcare professionals. By effectively addressing impulsive behaviors in patients with bipolar disorder, nurses can contribute to better outcomes and improved quality of life for their patients.