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: In this scenario, the correct answer is D) Examine interventions for possible revision of the target date. The rationale behind this choice is to ensure that the patient's care plan is effective in addressing the desired outcome of achieving a minimum of 5 hours of sleep nightly. By reviewing the patient's sleep data and considering the fact that they are taking a 2-hour afternoon nap, it is evident that the current plan may not be sufficient in meeting the desired goal. Option A) Continuing the current plan without changes may not lead to the desired outcome as the patient is not meeting the sleep goal. Option B) Removing the nursing diagnosis from the plan of care without addressing the issue would neglect the patient's needs. Option C) Writing a new nursing diagnosis may not be necessary if the current diagnosis is still relevant and the issue lies in the effectiveness of the interventions. Educationally, this question highlights the importance of continuous evaluation and adjustment of care plans based on patient responses and data. It emphasizes the need for critical thinking and flexibility in nursing practice to ensure optimal patient outcomes.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Disturbed thinking. In undifferentiated schizophrenia, one of the hallmark symptoms is disorganized thinking, which can manifest as thought disorder, delusions, or hallucinations. These symptoms are indicative of a primary deficit in thought processes. Option A) Social isolation may occur as a secondary consequence of the disturbed thinking and can be a symptom of schizophrenia, but it is not the primary deficit being assessed in this case. Option C) Altered mood states, while common in some types of schizophrenia, are not the primary deficit in undifferentiated schizophrenia. Mood disturbances are more characteristic of affective disorders. Option D) Poor impulse control is not typically a primary deficit in undifferentiated schizophrenia. While individuals with schizophrenia may exhibit impulsive behaviors, it is not the central feature of the disorder. Educationally, understanding the primary deficits in different psychiatric disorders is crucial for accurate assessment and treatment planning. By recognizing that disturbed thinking is the primary deficit in undifferentiated schizophrenia, healthcare professionals can target interventions to address this specific symptom and improve patient outcomes.

Correct Answer: D

Rationale: In this scenario, the correct nursing diagnosis for a patient who insists on being called "Your Highness" and exhibits loosely associated thoughts is "Disturbed thought processes" (Option D). This diagnosis is appropriate because the patient's behavior of demanding to be addressed as royalty and displaying loosely associated thoughts indicates a disruption in their cognitive processes and perception. Option A, "Risk for violence," is incorrect because the patient's behavior does not directly suggest a potential for physical harm to self or others. Option B, "Defensive coping," is incorrect as there is no evidence provided to support the patient using defensive mechanisms to manage stress or conflict. Option C, "Impaired memory," is also incorrect as the symptoms described do not specifically point to memory deficits but rather to disorganized thinking. Educationally, understanding the significance of different nursing diagnoses in psychiatric care is crucial for providing appropriate and effective patient-centered care. Recognizing and accurately identifying disturbed thought processes can guide interventions aimed at addressing the underlying cognitive challenges and promoting the patient's mental well-being. This rationale emphasizes the importance of thorough assessment and critical thinking in psychiatric nursing practice.

Correct Answer: B

Rationale: The correct answer is B) New findings suggest this disorder is biological in nature. This response is appropriate because it provides the mother with accurate information about the etiology of schizophrenia, which can help alleviate her feelings of guilt. By emphasizing the biological basis of the disorder, the response helps shift the focus away from blaming the mother and towards understanding that schizophrenia is not caused by any specific action or behavior. Option A) is incorrect because while it acknowledges the mother's feelings, it does not provide her with helpful information to address her guilt. Option C) may inadvertently reinforce the mother's feelings of guilt by implying that she needs to be strong for her daughter. Option D) is also incorrect as it does not address the mother's feelings of guilt or provide her with any useful information about schizophrenia. In an educational context, it is important for healthcare professionals to be able to provide accurate and up-to-date information to patients and their families, especially when it comes to sensitive topics like mental health. By understanding the biological basis of psychiatric disorders like schizophrenia, individuals can be better equipped to address misconceptions and reduce stigma surrounding these conditions.

Correct Answer: D

Rationale: The correct answer is D) Robinul decreases secretions to prevent aspiration during the ECT procedure. Glycopyrrolate, also known as Robinul, is an anticholinergic medication that works by reducing salivary and bronchial secretions. During ECT, patients are at risk of increased secretions due to the procedure's stimulation of the vagus nerve, which can lead to aspiration. Administering glycopyrrolate helps prevent this risk by drying secretions, reducing the likelihood of aspiration pneumonia and other respiratory complications. Option A is incorrect because glycopyrrolate does not primarily target anxiety reduction; its main action is on secretions. Option B is incorrect as glycopyrrolate does not induce unconsciousness or prevent pain. Option C is incorrect as the prevention of severe muscle contractions is not the main purpose of administering glycopyrrolate in this context. In an educational context, understanding the rationale behind administering medications before procedures is crucial for nurses to provide safe and effective care. Pharmacological knowledge, such as the mechanism of action of medications like glycopyrrolate, is essential for nurses to make informed decisions and prevent complications in their patients.