After assessing the patient and formulating the nursing diagnoses for a plan of care, what is the next action a nurse should take?

Determine the goals and outcome criteria

Design interventions to include in the plan of care

Implement the nursing plan of care

Complete the spiritual assessment

Answer and Explanation

The Correct Answer is A

Choice A reason: After diagnosis, setting goals and outcomes guides care, addressing issues like serotonin-driven depression. Goals, like “improve mood stability,” align with neurobiological needs, ensuring measurable, patient-centered targets. This step precedes interventions, forming the foundation for effective psychiatric treatment planning.

Choice B reason: Designing interventions follows goal-setting. Interventions, like therapy for dopamine imbalances, are based on established outcomes. Acting prematurely without goals risks misaligned care, as neurobiological targets must be defined first, making this step incorrect as the immediate next action.

Choice C reason: Implementation occurs after goals and interventions are set. Acting before defining outcomes, like stabilizing GABA for anxiety, risks ineffective care. The nursing process requires sequential planning to address neurobiological deficits, making implementation premature and incorrect at this stage.

Choice D reason: Spiritual assessment, while valuable, is part of initial data collection, not the next step after diagnosis. Goals addressing neurobiological issues, like serotonin deficits, take precedence to ensure targeted care. This option is irrelevant to the immediate planning phase of the nursing process.

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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.

A. Involuntary, excessive continuation or repetition of a single response or idea B. Has a lack of a logical relationship between thoughts, making the speech vague, diffuse, and unfocused C. Overproductive speech which rapidly moves from topic to topic with a tenuous logical link between topics D. Provides a lot of unnecessary detail, never returns to the central point, and never answers the question

Correct Answer is D

Explanation

Choice A reason: Involuntary repetition, or perseveration, involves repeating a single idea, often due to frontal lobe dysfunction in disorders like schizophrenia. Unlike tangential thinking, it fixates on one thought without divergence, making it distinct and incorrect for describing the diffuse, off-point speech of tangentially.

Choice B reason: Lacking logical relationships describes loose associations, not tangential thinking. Loose associations, seen in schizophrenia, reflect disorganized thoughts due to dopamine dysregulation, jumping illogically between ideas. Tangentiality diverges with excessive detail, staying somewhat related but off-point, making this option incorrect.

Choice C reason: Overproductive speech with tenuous links describes flight of ideas, common in mania with elevated dopamine. Unlike tangentiality, it involves rapid topic shifts with loose connections, not excessive detail missing the point. This distinction makes it an incorrect choice for tangential thinking.

Choice D reason: Tangential thinking involves excessive, irrelevant details, failing to return to the original question, often seen in schizophrenia or mania. This reflects disrupted executive function in the prefrontal cortex, impairing focus. The description matches this pattern, making it the correct choice for tangential speech.

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After assessing the patient and formulating the nursing diagnoses for a plan of care, what is the next action a nurse should take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Which of the following speech patterns is an example of tangential thinking?

Correct Answer is D

Explanation

Planning for patients diagnosed with mental illness is facilitated by understanding that inpatient hospitalization is generally reserved for a patient presenting with what characteristic?

Which statement shows a nurse has empathy for a patient who made a suicide attempt?

Which patient would a nurse refer to partial hospitalization?

A patient discloses several concerns and associated feelings. If the nurse wants to seek clarification, which comment would be appropriate?

“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?

Which remark by a patient indicates passage from the orientation phase to the working phase of a nurse-patient relationship?

A nurse explains to a nursing student how the therapeutic relationship differs from a social relationship. What is the best explanation for the therapeutic relationship between the nurse and patient?

After assessing the patient and formulating the nursing diagnoses for a plan of care, what is the next action a nurse should take?