A nurse is interviewing a client who is experiencing negative symptoms of psychosis about their family history of schizophrenia. In which of the following phases of the nursing process should this take place?
Implementation
Evaluation
Assessment
Planning
The Correct Answer is C
Choice A reason:
Implementation involves carrying out the interventions outlined in the care plan. This phase focuses on executing the planned actions to achieve the desired outcomes and does not include gathering initial information about the client’s history.
Choice B reason:
Evaluation involves assessing the effectiveness of the interventions and determining whether the goals of the care plan have been met. This phase occurs after the initial assessment and implementation of interventions.
Choice C reason:
Assessment is the first phase of the nursing process, where the nurse gathers comprehensive information about the client’s health status, including their family history of schizophrenia. This information is crucial for developing an accurate diagnosis and care plan.
Choice D reason:
Planning involves setting goals and determining the appropriate interventions based on the assessment data. While planning is essential, it follows the assessment phase and relies on the information gathered during the assessment.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","E","F"]
Explanation
Choice A reason:
Impaired interpersonal relationships can be a consequence of schizophrenia, but it is not a specific diagnostic criterion in the DSM-5. The criteria focus on more direct symptoms of the disorder.
Choice B reason:
Inability to initiate activities may be related to negative symptoms of schizophrenia, such as avolition, but it is not explicitly listed as a diagnostic criterion in the DSM-5. The criteria include more specific symptoms like disorganized behavior and hallucinations.
Choice C reason:
Disorganized behavior is one of the core symptoms of schizophrenia according to the DSM-5. It includes behaviors that are inappropriate or not goal-directed, reflecting a disruption in normal functioning.
Choice D reason:
Antisocial personality is a separate diagnosis and not a criterion for schizophrenia. Schizophrenia and antisocial personality disorder are distinct conditions with different diagnostic criteria.
Choice E reason:
Hallucinations are a key symptom of schizophrenia. They involve perceiving things that are not present, such as hearing voices or seeing things that others do not see. Hallucinations are one of the primary positive symptoms of schizophrenia.
Choice F reason:
Lack of emotional expression, also known as affective flattening, is a negative symptom of schizophrenia. It involves a reduced ability to express emotions and is a significant criterion in the diagnosis of schizophrenia.
Correct Answer is B
Explanation
Choice A reason:
Explaining unit rules and policies regarding unacceptable behaviors is important for maintaining order and safety within the facility. However, this action is more about setting boundaries and expectations rather than supporting the client’s autonomy. Autonomy involves respecting the client’s right to make their own decisions, which is not directly addressed by merely explaining rules.
Choice B reason:
Supporting the client’s wish to refuse prescribed medications demonstrates respect for the client’s autonomy. Autonomy is the ethical principle that recognizes the right of individuals to make informed decisions about their own care. By supporting the client’s decision to refuse medication, the nurse acknowledges and respects the client’s right to make choices about their treatment, even if those choices differ from medical advice.
Choice C reason:
Making sure the client understands expectations for client participation is essential for clear communication and effective treatment planning. However, this action is more about ensuring compliance and understanding rather than promoting autonomy. While it is important for clients to understand what is expected of them, this does not necessarily empower them to make their own decisions.
Choice D reason:
Encouraging client feedback about satisfaction with the facility experience is a valuable practice for improving care and ensuring that clients feel heard. However, this action focuses on gathering feedback rather than directly supporting the client’s autonomy. While it contributes to a client-centered approach, it does not specifically address the client’s right to make independent decisions about their care.
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