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: In this scenario, the correct answer is B) Assess the patient based on data collected from all sources. This is the most appropriate response for the nurse because it upholds the principles of comprehensive assessment and evidence-based practice in pharmacology and psychiatry. By choosing option B, the nurse ensures that the assessment is thorough and objective, taking into account all available information about the patient's condition. This approach allows for a holistic understanding of the patient's situation, which is crucial in psychiatry where accurate diagnosis and treatment are highly dependent on comprehensive assessment. Options A, C, and D are incorrect in this context. Documenting the other worker's assessment (Option A) without conducting an independent assessment may lead to biased conclusions. Validating the worker's impression by contacting the patient's significant other (Option C) introduces a potential for information bias and does not prioritize direct assessment of the patient. Discussing the worker's impression with the patient during the assessment interview (Option D) can also bias the nurse's perception of the patient before conducting a comprehensive evaluation. Educationally, this question emphasizes the importance of conducting independent, thorough assessments in pharmacology and psychiatry. It highlights the significance of evidence-based practice, critical thinking, and the need to gather information from multiple sources to make informed clinical decisions. It also underscores the ethical responsibility of healthcare professionals to maintain objectivity and avoid biases in patient care.

Correct Answer: C

Rationale: In this scenario, the correct answer is C) Impaired impulse control. Impaired impulse control refers to the inability to resist or control impulsive behaviors. In the case described, the patient's action of trying to gouge out their eye in response to auditory hallucinations demonstrates a significant lack of control over their impulses. Option A) Derealization is not the correct answer because derealization refers to feeling detached from one's surroundings, which is not the behavior exhibited by the patient in the question. Option B) Inappropriate affect is also incorrect as it refers to emotions that are not suitable for the circumstances, rather than impulsive behavior like attempting self-harm. Option D) Inability to manage anger is not the best choice because the behavior described is more indicative of impulse control issues rather than solely anger management problems. From an educational standpoint, understanding the concept of impaired impulse control is crucial in psychiatric nursing as it helps nurses recognize and respond to behaviors that may pose a risk to the patient or others. By differentiating between various psychiatric symptoms and behaviors, nurses can provide appropriate care and interventions to ensure patient safety and well-being.

Correct Answer: C

Rationale: In the context of a patient diagnosed with residual schizophrenia exhibiting ambivalence, choosing between two outfits to wear each morning (Option C) would be the most appropriate short-term outcome. This choice provides the patient with a manageable decision-making task that can help them practice making choices and regain a sense of control over their daily routine. Option A, deciding their own daily schedule, might be overwhelming for a patient struggling with ambivalence due to the high level of complexity involved. Option B, deciding which unit groups to attend, may also be challenging as it requires more cognitive load and decision-making capacity. Option D, choosing which clinic staff member to work with, may not directly address the ambivalence issue and may not be as relevant to daily functioning as choosing an outfit. In the educational context, it is important to understand that individuals with schizophrenia often struggle with decision-making and may benefit from structured tasks that gradually build their confidence in making choices. Providing opportunities for small, manageable decisions like choosing an outfit can be a valuable therapeutic intervention in addressing ambivalence in schizophrenia.

Correct Answer: A

Rationale: In the context of post-electroconvulsive therapy (ECT), it is crucial for the nurse to place the client on his or her side (Option A) to prevent aspiration. As ECT can induce confusion, disorientation, and muscle weakness immediately after the procedure, there is a risk of regurgitation and aspiration if the client is lying flat on their back. Placing the client on their side helps to ensure that any vomitus or secretions can easily drain out of the mouth, reducing the risk of aspiration pneumonia and other respiratory complications. Option B, placing the client in semi-Fowler's position to promote oxygenation, is incorrect in this scenario because the priority post-ECT is to prevent aspiration rather than focusing solely on oxygenation. Placing the client in Trendelenburg's position (Option C) could actually be harmful as it may increase intracranial pressure and is not indicated for this situation. Option D, placing the client in a prone position to prevent airway blockage, is also incorrect as lying prone could further increase the risk of aspiration. In an educational context, understanding the rationale behind positioning post-ECT is essential for nurses working in psychiatric settings. It not only ensures the safety and well-being of the client but also demonstrates the nurse's knowledge of proper post-procedural care. By prioritizing the prevention of aspiration in this scenario, nurses can provide effective and evidence-based care to clients undergoing ECT.

Correct Answer: A

Rationale: In the context of adolescent suicide risk assessment, option A, being sexually abused, is considered a high-risk factor for several reasons. Adolescents who have experienced sexual abuse may suffer from various psychological traumas, such as depression, anxiety, and post-traumatic stress disorder, which significantly increase their vulnerability to suicidal ideation and behavior. Options B, having experienced panic attacks, and C, being mildly cognitively impaired, while important factors to consider in a comprehensive psychiatric assessment, do not directly correlate with as high a risk of suicide in adolescents as a history of sexual abuse does. Panic attacks and cognitive impairments can contribute to mental health challenges but do not carry the same level of immediate risk as a history of sexual abuse. Option D, having a diagnosis of type 1 diabetes, is also a relevant factor to consider in the overall assessment of an adolescent's mental health and well-being. However, it is not typically considered as high a risk factor for suicide as a history of sexual abuse, which is more directly linked to mental health issues and suicidal behavior in adolescents. In an educational context, it is crucial for healthcare providers, particularly those in psychiatry or mental health fields, to be able to recognize and prioritize risk factors for adolescent suicide accurately. Understanding the significance of different risk factors can help in conducting thorough assessments, developing appropriate interventions, and implementing preventive strategies to support at-risk adolescents effectively.