When a female Mexican American patient and a female nurse sit together, the patient often holds the nurse's hand. The patient also links arms with the nurse when they walk. The nurse is uncomfortable with this behavior. Which analysis is most accurate?

Correct Answer: A

Rationale: The correct answer is A) The patient is accustomed to touch during conversation, as are members of many Hispanic subcultures. This is the most accurate analysis because different cultures have varying norms around touch and personal space. In many Hispanic subcultures, physical touch is a common form of communication and shows warmth and connection. Option B is incorrect because it assumes the patient is intentionally trying to make the nurse uncomfortable, which is unlikely in a healthcare setting where patients seek care and support. Option C is incorrect as it simplifies the situation to the patient seeking reassurance solely from physical touch, ignoring cultural nuances. Option D is incorrect as it unfairly labels the patient's behavior as manipulative without considering cultural influences. In an educational context, it is crucial for healthcare providers to understand and respect cultural differences in patient interactions. By recognizing and acknowledging these differences, nurses can provide more culturally sensitive care, build trust with patients, and enhance the overall quality of care provided.

Correct Answer: B

Rationale: The most appropriate response by the nurse in this scenario is option B: "Let's talk about what triggers your eating behaviors and how we can manage them." This response is the best choice because it demonstrates an understanding of the complexity of bulimia nervosa and the importance of addressing underlying triggers and developing coping strategies. Option A is incorrect because simply focusing on portion control and eliminating foods may oversimplify the issue and fail to address the emotional and psychological factors contributing to the patient's eating disorder. Bulimia nervosa is not just about food choices but also about underlying emotional issues. Option C is incorrect as suggesting strict dietary rules can exacerbate the patient's feelings of being out of control around food, leading to more guilt and shame, which are common triggers for binge eating episodes in individuals with bulimia nervosa. Option D is incorrect because assuring the patient that their fear will be overcome with time and therapy without addressing the specific concerns or triggers mentioned by the patient may come across as dismissive or not fully understanding the patient's current struggles. In an educational context, it is crucial for nurses to approach patients with eating disorders with empathy, understanding, and a holistic perspective that considers the psychological, emotional, and social factors contributing to the disorder. By addressing triggers and developing coping strategies, nurses can help patients make meaningful progress in managing their eating behaviors and promoting recovery.

Correct Answer: A

Rationale: In this scenario, the priority nursing intervention is option A) Ensure the patient is in a safe environment and assess for suicidal thoughts. This option is correct because the patient reporting hearing voices telling them to harm themselves indicates a high risk of self-harm or suicide. Therefore, ensuring the patient's immediate safety is paramount. Option B) Administer antipsychotic medication as prescribed may be necessary in the long term to manage schizophrenia symptoms, but it is not the immediate priority when the patient is at risk of self-harm. Option C) Encouraging the patient to engage in activities based in reality is important for grounding them, but it is not the priority when there is an imminent risk of harm. Option D) Validating the patient's hallucinations and offering reassurance may be helpful in some situations but is not appropriate when the patient is at risk of self-harm. Educationally, this question highlights the critical thinking and prioritization skills needed in nursing practice, especially when dealing with patients experiencing mental health crises. Understanding the urgency of certain interventions based on the patient's immediate needs is crucial for providing safe and effective care.

Correct Answer: C

Rationale: In this scenario, the correct answer is C) Implementation. In the nursing process, implementation is the phase where the nursing care plan is put into action. This is where the nurse carries out the interventions identified in the care plan to promote the patient's health and achieve the desired outcomes. Choosing option A) Assessment is incorrect because assessment is the phase where data is collected and analyzed to identify the patient's health needs. Encouraging a patient to attend a psychoeducational group daily is an intervention, not part of the assessment process. Option B) Analysis is also incorrect as this phase involves interpreting the data collected during assessment to identify problems, risks, and strengths. Encouraging a patient to attend a group daily is more about the action to be taken rather than analysis. Option D) Evaluation is incorrect because evaluation comes after the implementation phase. It is the stage where the nurse assesses the patient's response to the interventions implemented to determine if the outcomes have been achieved. Understanding the correct phase in the nursing process for implementing interventions is crucial for nurses to provide effective and efficient care to their patients. By correctly placing this intervention in the implementation phase, nurses can ensure that the care plan is being executed as intended to support the patient's health behavior change.

Correct Answer: A

Rationale: In this scenario, the priority nursing diagnosis is option A) Anxiety. Generalized anxiety disorder is characterized by excessive worrying and anxiety that is difficult to control. Addressing anxiety is crucial because it is the underlying issue affecting the patient's overall well-being and ability to function. By prioritizing the management of anxiety, the nurse can help the patient regain a sense of control and reduce the impact of anxiety on daily life. Option B) Imbalanced nutrition: Less than body requirements is not the priority in this case as it does not directly address the patient's primary concern of anxiety. While nutrition is important for overall health, addressing anxiety should come first to ensure the patient can engage in effective self-care practices. Option C) Ineffective coping is also relevant to the patient's situation, but it is secondary to addressing the anxiety itself. By managing the anxiety, the patient may be better able to develop and utilize effective coping mechanisms. Option D) Powerlessness is not the priority nursing diagnosis in this case as the patient's primary concern is related to managing anxiety. Powerlessness may be a factor contributing to the anxiety, but addressing the anxiety directly will likely have a greater impact on the patient's sense of empowerment. In an educational context, understanding the prioritization of nursing diagnoses is crucial for providing effective and efficient care. By recognizing the most pressing issue, nurses can tailor interventions to address the root cause of the patient's distress and promote better outcomes. In this case, the emphasis on managing anxiety aligns with evidence-based practice and holistic patient care.