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

Answer and Explanation

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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Correct Answer is B

Explanation

Choice A reason:
Libel involves making false and damaging statements about someone in written form. It is not relevant to the situation described, where the issue is the use of physical restraints on a voluntarily admitted client.

Choice B reason:
False imprisonment refers to the unlawful restraint of an individual against their will. In this case, applying physical restraints to a voluntarily admitted client who is demanding discharge could be considered false imprisonment if the restraints are not justified by the client’s behavior posing an immediate threat to themselves or others.

Choice C reason:
Medical beneficence refers to the ethical principle of acting in the best interest of the patient. While this principle guides nursing actions, it does not directly address the legal ramifications of using physical restraints.

Choice D reason:
Autonomy is the ethical principle that respects the patient’s right to make their own decisions. Restraining a voluntarily admitted client who wishes to leave the hospital can violate their autonomy. However, the legal issue at hand is more specifically related to false imprisonment.

A. ELECTROENCEPHALOGRAM (EEG) MONITOR B. OPHTHALMOSCOPE C. CARDIAC MONITOR D. BLOOD PRESSURE MONITOR E. PORTABLE X-RAY MACHINE

Correct Answer is ["A","C","D"]

Explanation

Choice A reason:
An electroencephalogram (EEG) monitor is essential for monitoring the brain’s electrical activity during ECT. This equipment helps ensure that the treatment is administered safely and effectively by providing real-time data on the patient’s brain waves. The EEG monitor is crucial for assessing the patient’s response to the therapy and detecting any abnormalities.
Choice B reason:
An ophthalmoscope is used to examine the interior structures of the eyes, which is not relevant to the ECT procedure. Therefore, it is not necessary to set up an ophthalmoscope in the room prior to ECT. The focus of ECT preparation is on monitoring the patient’s neurological and cardiovascular status, not on eye examinations.
Choice C reason:
A cardiac monitor is vital for tracking the patient’s heart rate and rhythm during ECT. This equipment helps detect any cardiac abnormalities or arrhythmias that may occur as a result of the treatment. Continuous cardiac monitoring ensures that any potential complications can be promptly addressed, making it an essential piece of equipment for ECT.
Choice D reason:
A blood pressure monitor is necessary for measuring the patient’s blood pressure before, during, and after the ECT procedure. Monitoring blood pressure is crucial for detecting any significant changes that could indicate cardiovascular stress or other complications. This equipment helps ensure the patient’s safety throughout the treatment.
Choice E reason:
A portable X-ray machine is not required for ECT. X-rays are used for imaging purposes, which are not part of the standard ECT procedure. The primary focus during ECT is on monitoring the patient’s neurological and cardiovascular status, making the portable X-ray machine unnecessary for this context.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse calls security and has physical restraints applied to a client who was admitted voluntarily when the client becomes verbally abusive, demanding to be discharged from the hospital. Which represents the possible legal ramifications for the nurse associated with these interventions?

Correct Answer is B

Explanation

A nurse is preparing to assist with electroconvulsive therapy (ECT). Which of the following pieces of equipment should the nurse set up in the room prior to the treatment? (Select all that apply)

Correct Answer is ["A","C","D"]

Explanation

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