A nurse works with a patient to establish goals/outcomes. The nurse believes that one outcome suggested by the patient is not in the patient’s best interest. What is the nurse’s best action?

Remain silent and add the suggested outcome to the plan

Formulate a more appropriate outcome without the patient’s input

Explore with the patient possible consequences of the outcome

Educate the patient that the outcome is not realistic

Answer and Explanation

The Correct Answer is C

Choice A reason: Silently adding an inappropriate outcome disregards patient safety and autonomy. Outcomes must align with neurobiological needs, like serotonin modulation for depression. This approach fails to engage the patient in decision-making, risking ineffective treatment and neglecting evidence-based collaborative care principles.

Choice B reason: Formulating outcomes without patient input violates autonomy. Collaborative goal-setting, considering neurobiological factors like dopamine imbalances, ensures patient engagement and effective treatment. Excluding the patient disregards their perspective, reducing adherence and therapeutic alliance, making this approach contrary to evidence-based psychiatric nursing.

Choice C reason: Exploring consequences respects autonomy while guiding patients toward safe outcomes. Discussing implications, like medication non-adherence worsening dopamine-driven symptoms, fosters informed decisions. This collaborative approach aligns with cognitive-behavioral principles and neurobiological treatment needs, ensuring effective, patient-centered care in psychiatric practice.

Choice D reason: Educating that an outcome is unrealistic may dismiss patient autonomy. While addressing neurobiological realities, like serotonin deficits, is important, unilateral education risks disengagement. Collaborative exploration of consequences is more effective, promoting informed choices and adherence, making this option less suitable than discussion.

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Correct Answer is A

Explanation

Choice A reason: Interventions, like offering snacks, address identified problems (e.g., forgetting to eat) to meet nutritional needs. This action targets physiological deficits, potentially linked to cognitive impairments from low acetylcholine in dementia, ensuring adequate caloric intake to support brain function and overall health in the care plan.

Choice B reason: Planning/goals outline desired outcomes, not specific actions. Forgetting to eat, possibly due to frontal lobe dysfunction, requires goals like “maintain adequate nutrition.” Interventions, not goals, specify actions like offering snacks, making this section incorrect for the statement’s placement in the care plan.

Choice C reason: Assessment involves data collection, like observing eating patterns, not actions like offering snacks. Forgetting to eat may reflect cognitive deficits, but assessment identifies the problem, not solutions. This section precedes interventions, making it an incorrect location for the described statement.

Choice D reason: Diagnosis identifies problems, like “impaired nutrition” due to cognitive deficits, not specific actions. Offering snacks is an intervention to address the diagnosis, not the diagnosis itself. This section is incorrect for the statement, which belongs in the intervention phase of the care plan.

A. The policies do not absolve an individual nurse of the responsibility to practice according to professional standards of nursing care B. In an institution with substandard policies, the nurse has a responsibility to inform the supervisor and leave the premises C. Agency policies are the legal standard by which a professional nurse must act and therefore override other standards of care D. Interpretation of policies by the judicial system is rendered on an individual basis and therefore cannot be predicted

Correct Answer is A

Explanation

Choice A reason: Nurses must adhere to professional standards, ensuring safe care despite substandard policies. Restraint use, for example, must minimize harm and respect patient dignity, regardless of policy. This aligns with ethical principles and evidence-based practices for managing agitation linked to neurotransmitter imbalances, upholding nurse accountability.

Choice B reason: Leaving the premises after informing a supervisor abandons patients, violating ethical duties. Professional standards require nurses to advocate for safe practices, like appropriate restraint use for dopamine-driven agitation, within the system. This option is impractical and neglects patient care responsibilities, making it incorrect.

Choice C reason: Agency policies do not override professional standards. Nurses are accountable to evidence-based practices, ensuring interventions like restraints for severe agitation are safe and ethical. Policies may guide but cannot excuse deviations from standards addressing neurobiological safety needs, making this option scientifically and ethically incorrect.

Choice D reason: Judicial interpretation varies, but nursing practice is guided by professional standards, not unpredictable legal outcomes. Standards ensure safe, ethical care, like minimizing restraint use for serotonin-related agitation, regardless of policy or judicial variability. This option is irrelevant to guiding daily nursing practice.

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A nurse works with a patient to establish goals/outcomes. The nurse believes that one outcome suggested by the patient is not in the patient’s best interest. What is the nurse’s best action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Your patient sometimes forgets to eat. In which part of the nursing care plan would the nurse expect to find this statement: “Offer snacks and finger foods frequently”?

Correct Answer is A

Explanation

Several nurses are concerned that agency policies related to restraint and seclusion are inadequate. Which statement about the relationship of substandard institutional policies and individual nursing practice should guide nursing practice?

Correct Answer is A

Explanation

How does a psychiatric nurse best implement the ethical principle of autonomy?

A patient prescribed a muscarinic-receptor blocker will require assessment for what side effect?

A patient presents with anxiety, increased heart rate, and fear. The nurse suspects the activation of which neurotransmitter?

On the basis of current knowledge of neurotransmitter effects, a nurse anticipates that the treatment plan for a patient with memory difficulties may include medications designed to do what?

“I’m concerned whether we are behaving ethically by restraining one patient to prevent them from self-mutilating while placing another patient on one-on-one supervision to prevent them from self-mutilating.” Which ethical principle most clearly applies to this situation?

How can the mental health nurse best advocate for individuals with mental illness and prevent stigmatization?

A client experiences panic attacks when confronted with riding in elevators. The nurse is teaching the client to use relaxation techniques while gradually exposing the client to getting on an elevator. Which technique is the nurse using?

A patient says to the nurse, “I dreamed I was pusillanimous. When I woke up, I felt emotionally drained, as though I hadn’t rested well.” Which comment would be appropriate if the nurse seeks clarification?