Which issues should a nurse address during the first interview with a patient with a psychiatric disorder?

Correct Answer: C

Rationale: The correct answer is C because during the first interview with a patient with a psychiatric disorder, it is crucial for the nurse to address relationship parameters to establish a therapeutic alliance, discuss the contract to clarify roles and expectations, ensure confidentiality to build trust, and explain termination to manage expectations. These aspects lay the foundation for a successful therapeutic relationship. A: Trust, congruence, attitudes, and boundaries - While trust and boundaries are important, they are part of relationship parameters addressed in choice C. Congruence and attitudes are more about the nurse's behavior than issues to address with the patient initially. B: Goals, resistance, unconscious motivations, and diversion - These are important aspects, but they are more relevant in later stages of therapy after a strong therapeutic alliance has been established. D: Transference, countertransference, intimacy, and developing resources - These are advanced concepts that may be addressed later in therapy as trust and rapport are established.

Correct Answer: C

Rationale: The correct answer is C because validation therapy involves acknowledging and validating the person's feelings and reality. By reiterating the patient's desire to go home and prepare dinner for her husband, the nurse validates the patient's emotions and reality, which can help reduce distress and agitation. Choice A is incorrect because it simply redirects the patient without acknowledging her feelings or reality. Choice B is incorrect because it focuses on the patient's widow status rather than validating her current feelings and beliefs. Choice D is incorrect because it introduces a potentially negative and untrue statement about the patient's husband, which could escalate the situation rather than providing validation.

Correct Answer: A

Rationale: The correct answer is A. Self-injurious behavior in individuals with borderline personality disorder is often a maladaptive coping mechanism used to relieve intense emotional distress or stress. This behavior is a way for the individual to externalize internal pain and gain a sense of control. It is important for the nurse to provide accurate information to the client's sister. Choice B is incorrect because self-injurious behavior in BPD is not typically used to calm or sedate individuals. Choice C is incorrect because self-injury is not usually a mechanism to avoid delusional thinking in BPD. Choice D is incorrect because while mood swings are common in BPD, self-mutilation is not typically used to slow them down.

Correct Answer: A

Rationale: The correct answer is A: Risk for Injury. Insomnia and sleep deprivation can lead to cognitive impairment and physical fatigue, increasing the risk of accidents and injuries. The nurse's priority is ensuring the client's safety. Option B, Ineffective Coping, focuses on emotional response rather than immediate safety concerns. Option C, Deficient Knowledge, does not directly address the client's current safety issue. Option D, Anxiety, is important but may not pose an immediate threat to safety compared to the risk of injury from sleep deprivation.

Correct Answer: D

Rationale: The correct answer is D: transitional challenges. Young adults often face significant changes in various aspects of their lives such as transitioning from school to work or moving out of their parents' home. This can lead to stress, anxiety, and depression. Developmental delays (A) typically refer to delays in reaching developmental milestones during childhood. An increase in comorbidities (B) may not necessarily be the main mental health challenge faced by young adults. Polypharmacy (C) is the use of multiple medications, which is more related to physical health challenges rather than mental health challenges in young adults. In summary, transitional challenges are the main mental health challenge for young adults due to the significant life changes they experience during this period.

Correct Answer: D

Rationale: The correct answer is D because clubhouse programs are known for being primarily run by psychiatric patients with minimal assistance from mental health staff. This model emphasizes empowerment, peer support, and self-help. It promotes a sense of community and belonging among members, allowing individuals to take an active role in their recovery. Choice A is incorrect because clubhouses are not typically open 24 hours a day. They usually operate during standard business hours. Choice B is incorrect because clubhouses are not run entirely by psychiatric mental health nurses. While mental health staff may be present, the focus is on peer support and collaboration among members. Choice C is incorrect because the primary focus of clubhouses is not on providing ongoing intensive psychotherapy. Instead, they emphasize socialization, skill-building, and vocational support in a non-clinical setting.

Correct Answer: A

Rationale: The correct answer is A because four-point restraints are used for clients who pose an imminent danger to themselves or others due to violent behavior, such as being hostile and threatening. Restraints should only be utilized as a last resort to ensure safety. Choices B, C, and D do not warrant the use of restraints as they do not involve immediate physical harm or danger. De-escalation techniques and alternative interventions should be attempted before resorting to restraint use.

Correct Answer: B

Rationale: The correct answer is B: Staying close to a door. By staying close to a door, the nurse can have a quick exit strategy in case the situation escalates. This allows the nurse to maintain a safe distance from the potentially violent patient and increases the chances of a swift escape if needed. Using protective devices (A) can be helpful but may not always be accessible in a community clinic setting. Keeping the door closed for privacy (C) may limit escape routes and hinder quick exit. Wearing inexpensive jewelry to distract the patient (D) is not a safe or effective strategy in managing a potentially violent situation.

Correct Answer: C

Rationale: The correct answer is C because during the first interview with a patient with a psychiatric disorder, it is crucial for the nurse to address relationship parameters to establish a therapeutic alliance, discuss the contract to clarify roles and expectations, ensure confidentiality to build trust, and explain termination to manage expectations. These aspects lay the foundation for a successful therapeutic relationship. A: Trust, congruence, attitudes, and boundaries - While trust and boundaries are important, they are part of relationship parameters addressed in choice C. Congruence and attitudes are more about the nurse's behavior than issues to address with the patient initially. B: Goals, resistance, unconscious motivations, and diversion - These are important aspects, but they are more relevant in later stages of therapy after a strong therapeutic alliance has been established. D: Transference, countertransference, intimacy, and developing resources - These are advanced concepts that may be addressed later in therapy as trust and rapport are established.