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?

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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

Nurse is giving discharge instructions to a client who has a new ileostomy. The nurse should recognize that the teaching has been effective when the client states:

Correct Answer: B

Rationale: The correct answer is B because ileostomy typically drains liquid continuously due to the high fluid content of the small intestine. This statement indicates the client understands the normal function of their stoma. A is incorrect because medications for ileostomy patients are usually not enteric coated. C is incorrect because pouch system change frequency varies, often daily or every few days, not every two weeks. D is incorrect because the stoma will change in size during the healing process.

Question 3 of 5

A patient checks and rechecks electrical cords related to an obsessive thought that the house may burn down. The nurse and patient explore the likelihood of an actual fire. The patient states this event is not likely. This counseling demonstrates principles of

Correct Answer: D

Rationale: The correct answer is D: cognitive restructuring. This counseling technique involves challenging and changing irrational thoughts, like the fear of the house burning down, by exploring evidence and creating more balanced perspectives. In this scenario, the nurse and patient are addressing the patient's obsessive thought by examining the likelihood of an actual fire, which aligns with cognitive restructuring. A: Flooding involves exposing the patient to the feared stimulus at full intensity, which is not demonstrated in the scenario. B: Desensitization involves gradually exposing the patient to the feared stimulus, not directly challenging irrational thoughts. C: Relaxation techniques aim to reduce anxiety and stress but do not address the underlying irrational thoughts like cognitive restructuring does.

Question 4 of 5

How will the nurse evaluate if trust has been established with the client?

Correct Answer: C

Rationale: The correct answer is C because when the client states, "I'll tell you about my sister," it shows a willingness to share personal information, indicating a level of trust. This statement implies a desire for the nurse to know more about their personal life, which is a positive sign of trust being established. Choice A does not necessarily indicate trust as it could just be a statement of longing. Choice B shows resistance or defensiveness, which is not indicative of trust. Choice D does not directly relate to the nurse-client relationship and does not provide insight into trust being established.

Question 5 of 5

A patient's relationships are intense and unstable. The patient initially idealizes the significant other and then devalues him or her, resulting in frequent feelings of emptiness. This patient will benefit from interventions to develop which aspect of mental health?

Correct Answer: D

Rationale: The correct answer is D: Fulfilling relationships. Patients with intense and unstable relationships, idealization, devaluation, and feelings of emptiness likely have traits of borderline personality disorder. Developing fulfilling relationships is crucial in managing this disorder. It helps improve emotional stability, self-esteem, and coping skills. Effective work, communication skills, and productive activities are important but may not directly address the core issues of relationship instability and emotional dysregulation seen in this patient population.

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