Which technique will best communicate to a patient that the nurse is interested in listening?

Correct Answer: A

Rationale: Restating allows the patient to validate the nurse's understanding of what has been communicated. Restating is an active listening technique. Judgments should be suspended in a nurse-patient relationship. Close-ended questions such as 'Did you feel angry?' ask for specific information rather than showing understanding. When the nurse simply states that he or she understands the patient's words, the patient has no way of measuring the understanding.

Correct Answer: B

Rationale: In caring for a patient diagnosed with bipolar disorder in the manic phase, the priority nursing intervention is to select option B, which is to set firm boundaries and limit the patient's ability to make impulsive decisions. This is crucial because individuals in the manic phase of bipolar disorder often lack the ability to control their impulses and may engage in risky behaviors that can be harmful to themselves or others. By setting firm boundaries, the nurse can help maintain a safe environment for the patient and prevent potential negative outcomes. Option A, encouraging the patient to express their feelings and engage in social activities, may not be the priority in this situation as the patient's impulsivity and risk-taking behavior need to be addressed first to ensure safety. Option C, providing medications to control symptoms, is important but may not address the immediate need to manage the impulsive behavior. Option D, offering reassurance and allowing the patient to make their own decisions, could potentially worsen the situation by enabling further impulsive behavior without appropriate limits. Educationally, understanding the priority interventions in managing patients with bipolar disorder is essential for nurses working in behavioral health settings. This scenario highlights the importance of safety and boundary-setting when caring for individuals experiencing manic episodes, emphasizing the need for proactive and structured interventions to promote patient well-being.

Correct Answer: B

Rationale: In this scenario, the best nursing response is option B: "I understand that you are feeling fearful, but I don't see anyone following you." This response demonstrates empathy towards the patient's feelings of fear without validating the delusion. It acknowledges the patient's emotions while providing a reality-based perspective in a non-confrontational manner. Option A is incorrect because it directly denies the patient's delusion, which can lead to increased distress and potential breakdown of trust between the nurse and patient. Option C is a good response as well, but it does not address the patient's immediate emotional state or provide reassurance. Option D is inappropriate as it dismisses the patient's concerns and fails to address the underlying issue. In an educational context, nurses must learn to effectively communicate with patients experiencing delusions in a way that shows empathy, maintains therapeutic rapport, and gently guides the patient towards a shared understanding of reality. This approach is crucial in providing holistic care for individuals with mental health disorders and promoting a trusting nurse-patient relationship.

Correct Answer: B

Rationale: In this scenario, the most appropriate nursing diagnosis for a patient with generalized anxiety disorder who reports excessive worry about work, family, and health is option B) Anxiety. The rationale behind selecting "Anxiety" as the correct nursing diagnosis is that generalized anxiety disorder is characterized by excessive and uncontrollable worry about various aspects of life. Anxiety is a fundamental component of this disorder, and addressing it directly is crucial in providing effective nursing care. Option A) Ineffective coping may seem plausible, but it is not as specific to the primary symptom of anxiety that the patient is experiencing. While ineffective coping may be a secondary concern, the primary focus should be on addressing the anxiety itself. Option C) Disturbed thought processes is not the most appropriate nursing diagnosis for this patient as the primary issue lies in the emotional domain of anxiety rather than cognitive disturbances. Option D) Imbalanced nutrition: Less than body requirements is not relevant to the symptoms presented by the patient in the scenario and is not a priority compared to addressing the patient's anxiety. In an educational context, understanding the nuances of different nursing diagnoses is essential for providing accurate and effective care to patients. By selecting the most appropriate diagnosis, nurses can tailor their interventions to target the underlying issue, leading to improved patient outcomes and quality of care.

Correct Answer: D

Rationale: When the patient (primary source) is unable to provide information, secondary sources should be used, in this case, the family member. Later, more data may be obtained from other information sources familiar with the patient. An advanced practice nurse is not needed for this assessment; it is within the scope of practice of the staff nurse. Calling a mental health advocate is unnecessary.