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: 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.

Correct Answer: C

Rationale: The correct answer is C: The child believes they are responsible for the parent being punished. According to social learning theory, individuals learn behaviors through observation and modeling. In this scenario, the child has internalized the belief that they are the cause of the parent's punishment due to the abuse. This leads to feelings of guilt and distress when the parent is no longer allowed to visit. A: The child does not view abuse as desirable; it is a harmful behavior. B: While fear may be present, the core issue lies in the child's belief of responsibility. D: The parent blaming the child for the abuse does not align with the principles of social learning theory.

Correct Answer: C

Rationale: The correct answer is C because the patient expressing feeling sad and empty about leaving the therapy group is a normal response to the termination of therapy. This indicates that the patient has developed attachments and a sense of belonging within the group, which is a common aspect of group therapy. It shows emotional investment in the therapeutic process and signifies progress in the patient's emotional awareness and ability to express feelings. Choice A is incorrect because the statement does not necessarily indicate regression but rather a normal emotional response. Choice B is incorrect as it assumes unconscious motivations without evidence. Choice D is incorrect as it is not necessary to question the patient's readiness based on the provided statement.

Correct Answer: A

Rationale: The correct answer is A because involving the entire family in therapy sessions allows for a more comprehensive understanding of the family dynamics and how they may be contributing to the child's issues. By including all family members, the nurse can gather diverse perspectives and insights that can inform the treatment plan. This approach also promotes family unity and collaboration in addressing the child's problems. Option B is not the best response as it lacks a clear rationale for involving the whole family. Option C, while partially true, does not directly address the question raised by the mother. Option D emphasizes the importance of every family member's perceptions but does not specifically address the benefits of involving the entire family in therapy sessions.

Correct Answer: B

Rationale: The correct answer is B: Administer an as needed (prn) dose of acetaminophen. After ECT, it is common for patients to experience headaches as a side effect. Administering acetaminophen will help alleviate the headache and provide relief for the patient. It is important to address the patient's discomfort promptly and effectively. Choice A is incorrect because headaches after ECT are a common side effect and do not typically require immediate physician notification. Choice C is incorrect as progressive relaxation may not address the immediate headache symptoms. Choice D is also incorrect as physical activities may exacerbate the headache rather than provide relief. Administering acetaminophen is the most appropriate and efficient intervention in this situation.

Correct Answer: D

Rationale: The correct answer is D: Thinking associated with ageism. This is because the patient's statement reflects a negative stereotype about older adults, assuming they are limited to playing cards and reminiscing about the past. Ageism involves discrimination or prejudice based on someone's age, which can lead to stereotyping and marginalization. A: Failure to achieve developmental tasks - This choice does not directly relate to the patient's statement about ageism. B: Hypercritical behavior - The patient's statement does not indicate hypercritical behavior, but rather a biased perspective on aging. C: Paranoid thinking - The patient's statement does not demonstrate paranoid thinking, but rather a biased view of older adults based on ageist beliefs. In summary, the correct answer is D as the patient's remarks reflect ageist thinking, while the other choices do not align with the content of the patient's statement.

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: A

Rationale: The correct answer is A: Ambivalence and low self-esteem. The member's statement reflects conflicting emotions (ambivalence) about her worth compared to her husband's. This indicates low self-esteem, as she believes she is less valuable. Unresolved anger (B) would involve blaming her husband, not herself. A need for attention (C) is not evident, as she is sharing personal feelings. Depression (D) may be present, but the statement specifically points to self-deprecation, not just a general feeling of sadness.