The desired outcome for a patient experiencing insomnia is, "Patient will sleep for a minimum of 5 hours nightly within 7 days." At the end of 7 days, review of sleep data shows the patient sleeps an average of 4 hours nightly and takes a 2-hour afternoon nap. The nurse will document the outcome as:

Correct Answer: C

Rationale: The correct answer is C: Sometimes demonstrated. The rationale is that the patient is not consistently meeting the desired outcome of sleeping for a minimum of 5 hours nightly within 7 days. Although the patient is sleeping for an average of 4 hours nightly, the 2-hour afternoon nap indicates that the patient is not achieving the desired outcome consistently. Therefore, the nurse would document the outcome as "Sometimes demonstrated" to reflect that the patient is making progress towards the goal but has not fully achieved it. Choices A, B, and D are incorrect because the patient's sleep behavior does not align with being consistently, often, or never demonstrated based on the desired outcome criteria.

Correct Answer: A

Rationale: The correct answer is A: A neologism. A neologism is a made-up word or phrase that only has meaning to the individual. In this case, "frobitz" is not a known word in the English language, indicating a neologism. This suggests possible language or thought disorder. B: Loose associations involve disconnected or tangential thoughts. C: Delusional thinking involves fixed false beliefs. D: Circumstantial speech includes excessive, irrelevant detail before reaching the main point.

Correct Answer: D

Rationale: The correct answer is D, engage in reality-oriented conversation. This is appropriate because it helps the patient ground themselves in reality and potentially reduce the intensity of their delusions. By discussing real-life events and situations, the patient is encouraged to recognize the disparity between their delusional thoughts and actual reality. Choice A is incorrect as simply accepting the delusion as illogical does not actively address the patient's condition. Choice B, distinguishing external boundaries, is not as effective in directly challenging the delusional thoughts. Choice C, explaining the basis for the delusions, may not be helpful initially as the patient may not be receptive to logical explanations due to their distorted thinking.

Correct Answer: D

Rationale: The correct answer is D because it provides an empathetic response by acknowledging the concern of the parent and demonstrating an understanding of the genetic link between twins and schizophrenia. By citing a specific statistic (50%), it shows knowledge of the relationship between genetics and the development of schizophrenia in twins. Choice A is incorrect because it downplays the genetic influence by suggesting a small chance, which is not accurate. Choice B is incorrect because it dismisses the seriousness of the situation and does not address the genetics aspect of the disorder. Choice C is incorrect because it is not based on factual information and offers sympathy without addressing the genetic component of schizophrenia in twins.

Correct Answer: C

Rationale: The correct answer is C. It acknowledges the client's autonomy while also addressing their concerns. First, it recognizes the client's right to discontinue treatment. Second, it opens the door for a discussion to explore the client's worries and provide support. This response shows empathy and respects the client's decision-making. Choice A is incorrect because it dismisses the client's autonomy and fails to address their concerns. Choice B is not as appropriate as it suggests only talking to the doctor, missing the opportunity for the nurse to provide immediate support. Choice D is incorrect as it invalidates the client's experience of memory loss and fails to address their concerns.