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. What is the nurse's next action?

Questions 20

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ATI Capstone Mental Health Proctored Assessment Questions

Question 1 of 5

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. What is the nurse's next action?

Correct Answer: D

Rationale: The correct answer is D. The nurse should examine interventions for possible revision of the target date. This is because the patient is not meeting the desired outcome of sleeping for a minimum of 5 hours nightly within 7 days. By examining interventions, the nurse can assess the effectiveness of the current plan and make necessary adjustments to help the patient achieve the desired outcome. Continuing the current plan without changes (choice A) would not address the issue of the patient not meeting the sleep goal. Removing the nursing diagnosis from the plan of care (choice B) would neglect the patient's ongoing sleep difficulties. Writing a new nursing diagnosis (choice C) does not address the need to evaluate and adjust the current interventions.

Question 2 of 5

A 25-year-old woman who recently had abdominal surgery was admitted to the psychiatric unit, where it was determined that she had a borderline personality disorder. During the first week on the unit, it was determined that she also has diabetes. Her diabetes mellitus would be listed in which axis of her DSM-IV-TR diagnosis?

Correct Answer: C

Rationale: The correct answer is C: Axis III. Axis III in the DSM-IV-TR is used for medical conditions that are relevant to the individual's mental health diagnosis. In this case, the woman's diabetes would be listed on Axis III because it is a medical condition that can impact her mental health and treatment. Diabetes is a physical health issue that can affect emotional well-being and may influence the course of her psychiatric treatment. A: Axis I is for clinical disorders such as mood disorders or anxiety disorders. B: Axis II is for personality disorders and mental retardation. D: Axis IV is for psychosocial and environmental stressors. Therefore, the correct placement for the woman's diabetes mellitus in her DSM-IV-TR diagnosis would be on Axis III.

Question 3 of 5

A hospitalized patient diagnosed with depression asks the nurse, 'Should I go home this weekend?' Which response by the nurse uses the technique of reflection?

Correct Answer: A

Rationale: Step 1: Option A reflects the patient's question back to them without adding any personal interpretation, allowing them to further explore their feelings. Step 2: This technique of reflection demonstrates active listening and encourages the patient to delve deeper into their thoughts. Step 3: Option B is a therapeutic technique called clarification, not reflection. Option C is an example of paraphrasing. Option D is a form of confrontation, not reflection. Summary: Choice A is correct as it reflects the patient's question back to them, facilitating self-exploration. Choices B, C, and D are incorrect as they represent different communication techniques.

Question 4 of 5

A patient is being treated in an interdisciplinary clinic. During interactions with a patient who is receiving cognitive behavior therapy, which of the following would the nurse concentrate on first?

Correct Answer: C

Rationale: The correct answer is C: Identifying the underlying beliefs. In cognitive behavior therapy, identifying the underlying beliefs is crucial as they drive the patient's thoughts and behaviors. By focusing on these core beliefs first, the nurse can help the patient understand the root causes of their issues and work towards challenging and modifying them effectively. A: Identifying alternative explanations of an event - This step usually comes after identifying the underlying beliefs. B: Exploring evidence to support or refute the beliefs - This step comes after identifying the beliefs and is not the initial focus. D: Examining the real implications if the beliefs are true - This step is important but is typically addressed after identifying and working on the underlying beliefs.

Question 5 of 5

A group of nursing students is reviewing the physical changes that occur in older adults. The students demonstrate understanding of the information when they identify which of the following as contributing to the patient's risk for drug toxicity?

Correct Answer: A

Rationale: The correct answer is A: Reduced liver function. In older adults, liver function declines, affecting drug metabolism and clearance. This can lead to drug toxicity as medications may not be broken down effectively. Reduced liver function is a common age-related change that can impact the pharmacokinetics of drugs. Choices B, C, and D do not directly contribute to drug toxicity risk in older adults. Reduced brain gray matter volume, lower metabolic rate at rest, and decreased body water are not specifically related to drug metabolism and clearance. Thus, they are incorrect choices for contributing to the patient's risk for drug toxicity.

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