Several nurses are concerned that agency policies related to restraint and seclusion are inadequate. Which statement about the relationship of substandard institutional policies and individual nursing practice should guide nursing practice?

Correct Answer: A

Rationale: Step-by-step rationale for the correct answer (A): 1. Professional standards of nursing care are based on ethical principles and guidelines. 2. Nurses have a duty to provide safe and quality care, regardless of institutional policies. 3. Individual nurses are accountable for their actions and cannot solely rely on institutional policies. 4. Upholding professional standards ensures patient safety and ethical practice. Summary of why other choices are incorrect: - B: Agency policies are important but do not override professional standards of care. - C: Leaving the premises may not always be necessary; addressing concerns with the supervisor is a more appropriate initial step. - D: Judicial interpretation is not relevant to individual nursing practice within the institution.

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.

Correct Answer: B

Rationale: The correct answer is B because the statement "I'm going to give my sister my pottery collection when I get home" indicates future planning, suggesting the client may not see themselves owning the collection in the future due to suicidal ideation. Choices A, C, and D do not directly relate to suicidal ideation as they focus on positive activities or future plans that do not indicate self-harm intentions.