Before assessing a new patient, a nurse is told by another health care worker, "I know that patient. No matter how hard we work, there isn’t much improvement by the time of discharge." The nurse’s responsibility is to:

Correct Answer: B

Rationale: A nurse should maintain objectivity and conduct their own assessment, considering all sources of information.

Correct Answer: A

Rationale: The patient whose 16-year-old daughter was raped and killed while going on an errand for the patient would be determined to be at highest risk for dysfunctional grief. This traumatic event involves sudden and violent loss of a child, which can lead to complicated or dysfunctional grief reactions. The circumstances of the death, involving violence, unexpectedness, and the close relationship with the deceased, can significantly impact the grieving process. The patient may struggle with intense emotions, guilt, anger, and unresolved trauma, making them more vulnerable to experiencing dysfunctional grief. It is essential for healthcare professionals to provide appropriate support and interventions to help the patient navigate through this complex grieving process.

Correct Answer: D

Rationale: This statement is concerning because it suggests the teenager may still have access to dangerous means (in this case, a gun) and may not fully understand or take responsibility for the gravity of his previous suicidal attempt. The attachment to the gun is alarming.

Correct Answer: B

Rationale: Advanced practice nurses, such as psychiatric-mental health nurse practitioners, are qualified to prescribe medications, including psychotropics, as part of their expanded scope of practice. Other listed actions can also be performed by registered nurses.

Correct Answer: C

Rationale: Identifying triggers for hallucinations is a key step in managing symptoms effectively

Correct Answer: A

Rationale: Boundaries define responsibilities and duties to one’s self in relation to others. Setting boundaries is essential in establishing a safe and professional therapeutic relationship between a nurse and a patient. These boundaries help to create a clear understanding of each person's roles and responsibilities within the relationship. Boundaries also help protect both the nurse and the patient from potential harm, maintain professionalism, and ensure effective communication and focus on the therapeutic goals. By defining these boundaries, the nurse can better maintain appropriate relationships with patients and avoid conflicts of interest or ethical dilemmas.

Correct Answer: B

Rationale: Bereavement involves waves of emotional pain, often triggered by reminders of the loss, whereas depression typically causes persistent symptoms such as guilt or hopelessness.

Correct Answer: C

Rationale: The correct assessment to be made in this scenario is that the relationship is moving from the orientation phase to the working phase. In the orientation phase of the nurse-patient therapeutic relationship, the focus is on building rapport, establishing trust, and determining the patient's needs and goals. As the patient voluntarily expresses a desire to work on the issue of relationships, it indicates a transition to the working phase where the patient actively identifies problems to address and goals to achieve. This shift demonstrates progress in the therapeutic relationship as the patient is engaging in the therapeutic process and contributing to the agenda set for the appointment. It signifies a readiness for collaborative problem solving and intervention planning, emphasizing the importance of the patient's involvement in decision-making and goal-setting in the therapeutic process.

Correct Answer: C

Rationale: Residual schizophrenia can cause ambivalence or difficulty making decisions. Offering simple choices reduces decision-making stress and promotes autonomy.