A patient begins a new program to assist with building social skills. In which part of the plan of care should a nurse record the item, "Encourage patient to attend one psychoeducational group daily"?

Correct Answer: B

Rationale: The correct answer is B: Implementation. In the nursing process, implementation involves carrying out the plan of care. Encouraging the patient to attend a psychoeducational group daily is an action that is part of implementing the care plan to improve social skills. This step focuses on putting the plan into action and actively supporting the patient in achieving the desired outcomes. A: Assessment is incorrect because assessment involves collecting data and information about the patient's condition, not actively implementing interventions. C: Analysis is incorrect as it involves interpreting and making sense of the assessment data to identify problems and strengths, not implementing interventions. D: Evaluation is incorrect because it involves assessing the effectiveness of the interventions implemented, not actively carrying out the interventions themselves.

Correct Answer: B

Rationale: The correct answer is B: Age-appropriate language development. Asperger's disorder is characterized by normal to above-average language development, whereas autism typically presents with delays or impairments in language skills. This is important for planning care as it influences communication strategies and interventions for individuals with Asperger's. A: Repetitive patterns of behavior are more indicative of autism, not specific to Asperger's. C: Stereotypic movements and speech patterns are also more associated with autism and not a defining feature of Asperger's. D: Obsession with objects that move in a spinning motion is a specific behavior that may be seen in some individuals with autism, but it is not a defining characteristic of Asperger's disorder.

Correct Answer: C

Rationale: The correct answer is C because reorienting the patient to time, place, and person is crucial in the immediate post-ECT period to help the patient regain orientation as consciousness improves. This intervention helps prevent confusion and disorientation commonly experienced after ECT. A: Continually stimulating the patient may be overwhelming and unnecessary. B: Continuing bagging is not relevant after ECT as the patient's respiratory function should have stabilized. D: Encouraging walking and eating can be unsafe immediately post-ECT due to potential disorientation and muscle weakness.

Correct Answer: A

Rationale: The correct answer is A because it demonstrates active listening and shows empathy towards the patient, which can help them feel heard and understood. By inviting the patient to express their feelings and concerns, the nurse can help de-escalate the situation by addressing the underlying issues. Choice B is incorrect because it may come across as confrontational and could further provoke the patient's aggression. Choice C is also incorrect as it threatens the patient with consequences, which can escalate the situation. Choice D is not appropriate as it distracts from addressing the current issue of aggression and may not be well-received by the patient in that moment.

Correct Answer: B

Rationale: The correct answer is B because it captures the essence of bereavement - the experience of loss. This choice acknowledges that bereavement involves losing something significant, which is a universal aspect of grieving. Other choices are incorrect - A is not always predictable, C is not always acute depression, and D focuses on a specific aspect of grief rather than the core element of loss. Therefore, B is the most comprehensive and inclusive choice.

Correct Answer: D

Rationale: The correct answer is D because research indicates that suicides can occur accidentally as a result of self-injurious behaviors. This is known as an unintentional suicide, where the individual did not intend to die but died due to the severity of their self-injurious behavior. This information is crucial for planning safety interventions for the teenager, as it highlights the potential seriousness of self-injury. Choice A is incorrect because research shows that suicidal ideation is not uncommon among teenagers, so it cannot be assumed that they rarely entertain the idea of suicide. Choice B is also incorrect because while self-injury can be a risk factor for future suicidal attempts, it is not always the case. Choice C is relevant but not the most specific to the scenario presented in the question, as it focuses solely on suicidal ideations rather than the potential accidental outcomes of self-injury.

Correct Answer: A

Rationale: The correct answer is A because positive transference with a staff member in the orientation phase indicates a developing therapeutic relationship, which is crucial for effective treatment. This outcome shows the patient is beginning to trust and feel safe with a staff member, enhancing their engagement in therapy. Choice B is incorrect because the ability to ask for help in meeting needs may not be fully developed by the end of the orientation phase. Choice C is incorrect as commitment to long-term therapy is usually not established this early in the process. Choice D is incorrect because the ability to manage symptoms independently typically requires more time and therapy progress.

Correct Answer: B

Rationale: The correct answer is B: Concrete operational. At this developmental level, children typically exhibit the ability to focus, coordinate, and imagine a series of events. This stage, according to Piaget's theory, usually occurs around ages 7 to 11. Children at this stage can perform logical operations, understand conservation, and think more systematically. A: Preoperational - Children at this stage (ages 2-7) lack the ability to perform logical operations and struggle with understanding conservation and cause-and-effect relationships. C: Formal operational - This stage (typically starting around age 11) involves abstract thinking, hypothetical reasoning, and problem-solving beyond the concrete level. D: Postoperational - This term is not a recognized developmental stage in Piaget's theory.

Correct Answer: B

Rationale: The correct answer is B: To prevent anoxia due to medication-induced paralysis of respiratory muscles. During electroconvulsive therapy, muscle relaxants are often used to prevent injury during the seizure. These medications can lead to paralysis of respiratory muscles, causing potential anoxia if oxygen is not administered. Providing pure oxygen ensures adequate oxygenation despite muscle paralysis. Incorrect Choices: A: Preventing increased intracranial pressure is not the primary rationale for administering oxygen during ECT. C: Hypotension, bradycardia, and bradypnea are potential side effects of ECT itself, but oxygen administration is not primarily to prevent these. D: Oxygen is not administered to prevent a blocked airway but rather to ensure adequate oxygenation during muscle paralysis.