An aide in a psychiatric hospital says to the nurse, 'We don’t have time every day to help each patient complete a menu selection Let’s tell dietary to prepare popular choices and send them to our unit' Select the nurse’s best response

Correct Answer: B

Rationale: The correct answer is B: "Thanks for the idea, but it’s important to treat patients as individuals. Giving choices is one way we can respect patients’ individuality." This response is the best because it upholds the core principle of person-centered care in behavioral health nursing. It recognizes the importance of respecting patients' autonomy and individuality in the treatment process. By allowing patients to make their own menu selections, it empowers them to have a sense of control over their own care, which is crucial in promoting their mental well-being. Option A is incorrect because it focuses solely on the medical aspect of patients taking MAOI antidepressants and does not address the core issue of patient autonomy and individuality. Option C is incorrect because while the patient's bill of rights is important, the response does not directly address the need for individualized care and the importance of respecting patients' choices. Option D is incorrect because it dismisses the importance of individualized care and patient autonomy in favor of convenience for the dietary department. This response does not align with best practices in behavioral health nursing, which prioritize the holistic needs of the patient. In an educational context, this question highlights the significance of person-centered care in psychiatric settings. It emphasizes the importance of treating patients with respect, dignity, and individuality to promote positive outcomes in their mental health recovery journey. Educating nurses on the principles of person-centered care can enhance their practice and improve patient satisfaction and outcomes.

Correct Answer: B

Rationale: In behavioral health nursing, after formulating nursing diagnoses for a new patient, the next crucial step is to determine the goals and outcome criteria, making option B the correct answer. This is because setting clear and achievable goals is essential in guiding the nursing care provided to the patient. By determining the goals and outcome criteria, the nurse establishes a framework for evaluating the effectiveness of the interventions planned. Option A, designing interventions, is an important step in the nursing process, but it should come after setting the goals. Without clear goals, interventions may not be targeted or effective. Option C, implementing the nursing plan of care, is also a critical step, but it comes after both formulating the diagnoses and setting the goals. Completing the spiritual assessment, as mentioned in option D, is important in holistic care but is not the immediate next step after formulating nursing diagnoses. In an educational context, understanding the sequential nature of the nursing process is essential for nursing students to provide safe and effective patient care. By emphasizing the importance of setting goals and outcome criteria, educators can help students develop critical thinking skills in planning and implementing nursing care. This rationale reinforces the significance of prioritizing steps in the nursing process to optimize patient outcomes.

Correct Answer: D

Rationale: In the context of Behavioral Health Nursing, understanding the concept of delusions is crucial for assessing and managing patients with various psychiatric disorders. A delusion is a fixed, false belief that is resistant to reason or factual evidence. The correct answer to the question is option D) Thinking. A delusion represents a problem in the area of thinking because it is a manifestation of a cognitive distortion where an individual's thought process is altered, leading them to believe in something that is not based on reality or evidence. Delusions impact how a person perceives and interprets information, affecting their overall thought patterns. Option A) Memory is incorrect because delusions are not primarily related to memory deficits. Option B) Motivation is incorrect as delusions are more about distorted beliefs rather than motivational issues. Option C) Orientation is incorrect because orientation refers to awareness of self, time, and place, whereas delusions are about false beliefs. Educationally, understanding the nature of delusions helps nurses in accurately assessing and planning care for patients with psychotic disorders such as schizophrenia. By recognizing delusions as a thinking problem, nurses can implement interventions to address cognitive distortions, promote reality testing, and enhance therapeutic communication with patients experiencing delusions. This knowledge is vital for providing holistic care and improving patient outcomes in behavioral health settings.

Correct Answer: A

Rationale: These questions would elicit information about the client's intellectual function. Insight is the ability to understand the true nature of one's situation and accept some personal responsibility for that situation. Judgment refers to the ability to interpret one's environment and situation correctly and to adapt one's behavior and decisions accordingly. Questions about memory would require that the client identify knowledge of past events.

Correct Answer: C

Rationale: The client has a delusion (a fixed false belief not based in reality) about his superiority over others. Flight of ideas is excessive amount and rate of speech composed of fragmented or unrelated ideas. Thought broadcasting is a delusional belief that others can hear or know what the client is thinking. Loose associations are disorganized thinking that jumps from one idea to another with little or no evident relation between the thoughts.