The nurse is doing an assessment interview of a patient. During the interview, the patient comments, 'Our people are connected with nature. Our world, our seasons, and our weather—they all have many lessons to teach us.' The nurse interprets the patient's statement as an expression of which of the following?

Correct Answer: C

Rationale: The correct answer is C: Spirituality. The patient's statement reflects a deep connection to nature and the belief that nature holds valuable lessons. This aligns with the concept of spirituality, which involves seeking meaning and purpose in life beyond material possessions. The patient's emphasis on nature suggests a spiritual perspective that values interconnectedness and the wisdom of the natural world. Religiousness (A) typically refers to adherence to specific organized beliefs and practices. Tribal law (B) pertains to legal systems within specific cultural groups. Ecological values (D) focus more on environmental conservation and sustainability, rather than the spiritual or philosophical connection to nature expressed by the patient.

Correct Answer: C

Rationale: The correct answer is C: Ignore the child's rocking behavior. This is the most appropriate intervention because rocking without any danger does not require immediate intervention. It is a self-soothing behavior often seen in children with autism. By ignoring the behavior, the nurse avoids reinforcing it and allows the child to engage in self-regulation. Monitoring the behavior (choice A) is appropriate but does not actively address the behavior. Holding the child (choice B) may disrupt the child's coping mechanism. Placing the child in time out (choice D) is not appropriate as it may be perceived as punishment and increase distress.

Correct Answer: D

Rationale: The correct answer is D because it addresses the specific concern of the client with schizophrenia who also abuses alcohol. By monitoring and reporting any side effects, the nurse can ensure that the client's prescribed medications are adjusted or changed as needed to prevent him from stopping his medication, which could lead to relapse. This approach promotes medication adherence and overall stability, thus reducing the risk of relapse. Option A is incorrect because it lacks proactive measures to support the client's recovery. Option B focuses solely on avoiding triggers related to delusional thinking and does not address the dual diagnosis of schizophrenia and alcohol abuse. Option C, while beneficial, may not fully address the client's unique needs and challenges related to his dual diagnosis.

Correct Answer: C

Rationale: The correct answer is C: Spirituality. The patient's statement reflects a deep connection to nature and the belief that nature holds valuable lessons. This aligns with the concept of spirituality, which involves seeking meaning and purpose in life beyond material possessions. The patient's emphasis on nature suggests a spiritual perspective that values interconnectedness and the wisdom of the natural world. Religiousness (A) typically refers to adherence to specific organized beliefs and practices. Tribal law (B) pertains to legal systems within specific cultural groups. Ecological values (D) focus more on environmental conservation and sustainability, rather than the spiritual or philosophical connection to nature expressed by the patient.

Correct Answer: B

Rationale: The correct answer is B: Determining the goals and outcome criteria. After formulating nursing diagnoses, the nurse's next action should be to establish clear goals and outcome criteria to guide the plan of care. This step ensures that the interventions are focused on achieving specific outcomes for the patient's health. Designing interventions (choice A) comes after setting goals. Implementing the nursing plan of care (choice C) is done after determining goals and interventions. Completing the spiritual assessment (choice D) is important but typically not the immediate next step after formulating nursing diagnoses.