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 B

Explanation

Choice A reason: Labeling paranoia as a loss of reality, while accurate for dopamine-driven delusions, risks alienating the patient. Confronting beliefs directly can increase agitation, as the amygdala amplifies fear responses. A therapeutic response validates emotions, not challenges perceptions, making this less effective.

Choice B reason: Acknowledging privacy concerns validates the patient’s emotions without reinforcing delusions. This reduces anxiety, calming amygdala hyperactivity in paranoia, and builds trust. By focusing on feelings, not the delusion’s content, the nurse fosters a therapeutic alliance, aligning with evidence-based approaches for psychotic disorders.

Choice C reason: Stating government prohibition addresses the delusion’s content, potentially escalating agitation. Paranoia, driven by mesolimbic dopamine excess, resists factual correction. This risks confrontation, undermining trust and therapeutic rapport, making it less effective than validating emotions in managing psychotic symptoms.

Choice D reason: Redirecting to another topic avoids engaging with the patient’s emotional state, missing a therapeutic opportunity. Paranoia, linked to dopamine dysregulation, requires addressing underlying fears to reduce amygdala-driven anxiety. Ignoring the concern can increase mistrust, making this response less therapeutic.

A. Freedom from restraints or seclusion B. Refusal of treatment during an emergency situation C. Access to one’s own mental health records upon request D. An individualized written treatment plan

Correct Answer is B

Explanation

Choice A reason: Freedom from restraints or seclusion is a recognized right unless safety is compromised. Restraints, used for severe agitation linked to dopamine or serotonin imbalances, must be justified and minimized to respect patient dignity, aligning with ethical standards in mental health care, making this a valid right.

Choice B reason: Refusing treatment in emergencies, such as acute psychosis with safety risks, is not a right. Emergency interventions, like antipsychotics for dopamine-driven hallucinations, prioritize safety over autonomy. Legal frameworks allow treatment without consent in such cases, making this an incorrect right, requiring further discussion.

Choice C reason: Access to mental health records is a patient right, supporting autonomy and transparency. Understanding one’s diagnosis, like serotonin-related depression, empowers informed decisions. This right is protected under health privacy laws, ensuring patients can review their neurobiological and treatment data, making it a valid right.

Choice D reason: An individualized treatment plan is a right, ensuring care tailored to specific neurobiological needs, like dopamine modulation in schizophrenia. This promotes effective treatment and patient involvement, aligning with ethical standards. It is a recognized right in mental health care, not requiring further discussion.

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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

A patient with paranoia states, “The state is monitoring us through the listening devices hidden in this room. Be careful what you say.” Which response by the nurse would be most therapeutic?

Correct Answer is B

Explanation

After teaching a class about the rights of persons receiving mental health services, the nurse determines a need for additional discussion when the group wrongly identifies which as a right?

Correct Answer is B

Explanation

A client is experiencing a panic attack. What medication will provide the quickest relief from acute severe anxiety symptoms?

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?

After several therapeutic encounters with a patient who recently attempted suicide, which occurrence should cause the nurse to consider the possibility of countertransference?

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

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

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

A patient is undergoing diagnostic tests. The patient says, “Nothing is wrong with me except a stubborn chest cold.” The spouse reports that the patient smokes, coughs daily, has recently lost 15 pounds, and is easily fatigued. Which defense mechanism is the patient using?