The nurse assesses an adult who is socially withdrawn and hoards. Which nursing diagnoses most likely apply to this individual? (Select all that apply.)

Correct Answer: A

Rationale: In this scenario, the correct nursing diagnosis that most likely applies to an adult who is socially withdrawn and hoards is "A) Ineffective home maintenance." This diagnosis is appropriate because the individual's behaviors indicate difficulties in maintaining a safe and healthy living environment due to social withdrawal and hoarding tendencies. Option B, "Situational low self-esteem," and option C, "Chronic low self-esteem," are incorrect in this context because the symptoms described do not directly point to self-esteem issues. While low self-esteem can contribute to behavioral health issues, the primary concern in this case is the individual's ability to maintain their living environment. Option D, "Disturbed body image," is also incorrect because this diagnosis is typically associated with perceptions related to one's physical appearance, which is not the primary concern indicated by the individual's behavior of social withdrawal and hoarding. From an educational perspective, understanding how to analyze behavioral symptoms and connect them to appropriate nursing diagnoses is crucial for effective patient care. Nurses need to be able to assess behaviors, understand their implications, and apply appropriate diagnoses to provide targeted interventions and support for individuals experiencing mental health challenges.

Correct Answer: D

Rationale: The correct response is D) "Posttraumatic stress disorder often strains relationships. Here are some community resources for help and support." This response is the best choice because it acknowledges the potential impact of PTSD on relationships and offers concrete support through community resources. It shows empathy and provides practical assistance to address the spouse's concerns. Option A is incorrect because it solely focuses on sexual functioning, which may not be the primary concern in this situation. Option B is not appropriate as it suggests avoiding the issue rather than addressing it directly. Option C oversimplifies the situation by suggesting a straightforward confrontation without considering the complexities of PTSD and its effects on behavior. In an educational context, it is crucial for nurses to understand the multifaceted impact of PTSD on individuals and their relationships. By providing support, resources, and guidance, nurses can effectively assist both the individual with PTSD and their loved ones in navigating challenges and seeking appropriate help. Effective communication skills and knowledge of community resources are essential in addressing the needs of individuals and families affected by PTSD.

Correct Answer: B

Rationale: In the context of caring for a patient diagnosed with somatic symptom disorder, it is crucial for a medical-surgical nurse to understand the possible patient responses to psychiatric help. The correct answer, B) be resistant to accepting psychiatric help, is based on the typical behavior of individuals with somatic symptom disorder. These patients often struggle to accept or acknowledge the psychological aspects of their symptoms, leading to resistance when offered psychiatric interventions. Option A) readily seek psychiatric counseling is incorrect because individuals with somatic symptom disorder often have difficulty accepting the psychological nature of their symptoms and may be hesitant to seek psychiatric help voluntarily. Option C) attend psychotherapy sessions without encouragement is also incorrect as individuals with this disorder typically resist psychiatric interventions, making it unlikely for them to attend psychotherapy sessions without significant resistance. Option D) be eager to discover the true reasons for physical symptoms is incorrect because individuals with somatic symptom disorder often have a strong belief in the physical nature of their symptoms and may not be eager to explore underlying psychological factors. Educationally, understanding the typical responses of patients with somatic symptom disorder is essential for nurses to provide effective care and support. By recognizing the potential resistance to psychiatric interventions, nurses can tailor their approach to build trust and rapport with the patient, ultimately improving outcomes and promoting holistic care.

Correct Answer: A

Rationale: This patient is experiencing anxiety associated with a serious medical condition. Verbalization is an effective outlet for anxiety. "I'm wondering if you are anxious "¦" focuses on the emotions underlying the behavior rather than the behavior itself. This opening conveys the nurse's willingness to listen to the patient's feelings and an understanding of the commonly seen concern about not having a nurse always nearby as in the intensive care unit. The other options focus on the behavior or its impact on nursing and do not help the patient with her emotional needs.

Correct Answer: A

Rationale: There is no chronic disease to explain the symptoms for patients with somatic symptom disorder. Patients report multiple symptoms; gastrointestinal and pseudoneurological symptoms are common. This disorder is more common in women than in men. Patients with conversion disorder would have a tendency to underrate pain.