A patient diagnosed with severe and persistent mental illness lives in a homeless shelter. The priority nursing diagnosis for this patient is Powerlessness. Which intervention should be included in the plan of care?

Correct Answer: A

Rationale: The correct answer is A: Encourage mutual goal setting. This intervention is crucial as it empowers the patient to take an active role in their care, promoting autonomy and self-efficacy. By involving the patient in setting goals, it helps them regain a sense of control and combat feelings of powerlessness. It also fosters a collaborative relationship between the patient and the healthcare team, enhancing trust and engagement in the treatment process. Incorrect choices: B: Verbally communicate empathy - While empathy is important, it does not directly address the issue of powerlessness. C: Reinforce participation in activities - While participation in activities can be beneficial, it may not address the underlying issue of powerlessness. D: Demonstrate an accepting attitude - While acceptance is important, it may not empower the patient to actively participate in their care and address feelings of powerlessness.

Correct Answer: C

Rationale: The correct nursing diagnosis is C: Situational low self-esteem. The patient's statement reflects a negative self-perception related to the recent termination of employment, indicating situational low self-esteem. This diagnosis focuses on a specific event affecting self-worth. Choice A, Powerlessness, would be more appropriate if the patient expressed a lack of control in their situation. Choice B, Defensive coping, would apply if the patient was using defensive mechanisms to protect themselves from the emotional impact of job loss. Choice D, Disturbed personal identity, would be relevant if the patient had a significant disruption in self-concept beyond just low self-esteem.

Correct Answer: A

Rationale: The correct answer is A because the statement reflects a clear false belief (delusion) that the television is sending secret messages to the patient. This belief is not based on reality or evidence. In contrast, choices B, C, and D do not demonstrate delusional thinking. Choice B expresses general distrust, choice C suggests a feeling of being watched due to a perceived special status, and choice D indicates auditory hallucinations, not delusional thoughts. Delusions are fixed, false beliefs that are not culturally accepted or based on factual evidence.

Correct Answer: A

Rationale: The correct answer is A because ensuring the patient is in a safe environment and monitoring for physical harm is the top priority during acute mania. This intervention focuses on preventing any harm to the patient or others, which is crucial in managing acute mania. It prioritizes safety and can help prevent any potential dangerous situations. Encouraging group activities (choice B) may not be effective during acute mania as the patient may not be able to participate safely. Administering a sedative (choice C) without ensuring safety first can lead to potential risks. Offering medication (choice D) should be done after ensuring the patient's safety.

Correct Answer: C

Rationale: Step 1: Chronic trauma refers to repeated exposure to traumatic events over a prolonged period, such as ongoing abuse and neglect in this case. Step 2: The adolescent has experienced abuse and neglect since early childhood, indicating a long-term and persistent traumatic experience. Step 3: Vicarious trauma involves indirect exposure to trauma through witnessing or hearing about others' experiences. Step 4: Acute trauma refers to a single traumatic event with immediate impact, not a prolonged pattern like chronic trauma. Step 5: Historical trauma relates to collective trauma experienced by a group over generations, not an individual's ongoing abuse and neglect. Summary: Choice C is correct because it best describes the repeated and prolonged nature of the adolescent's traumatic experiences, while the other choices do not align with the specific circumstances presented.