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 D

Explanation

Choice A reason: Canceling discharge overrides patient autonomy and recovery progress. Stabilized schizophrenia, managed with antipsychotics targeting dopamine, supports discharge with adherence. This action disregards the patient’s rights and neurobiological stabilization, making it an inappropriate advocacy response.

Choice B reason: Notifying security dismisses family concerns and escalates unnecessarily. Schizophrenia management relies on medication adherence, not coercion. This approach ignores patient rights and family education needs, failing to address neurobiological treatment principles, making it incorrect for advocacy.

Choice C reason: Transferring to long-term care assumes ongoing instability, ignoring current stabilization. Antipsychotics correct dopamine imbalances, supporting outpatient management. This undermines patient autonomy and recovery potential, making it an inappropriate advocacy action for a stabilized patient.

Choice D reason: Explaining medication adherence promotes patient autonomy and recovery. Antipsychotics reduce dopamine-driven hallucinations, ensuring symptom control. Educating the family empowers support for adherence, aligning with patient rights and neurobiological treatment principles, making this the correct advocacy response.

A. The client should not stop this medication abruptly to avoid discontinuation syndrome B. The client may experience frequent constipation and should increase their intake of dietary fiber C. This medication takes 4-6 months to be effective, the client should be told to be patient D. This medication can cause addiction, so the client should not take more than prescribed

Correct Answer is A

Explanation

Choice A reason: Abruptly stopping fluoxetine, an SSRI, disrupts serotonin levels, causing discontinuation syndrome with symptoms like dizziness and irritability due to rapid neurotransmitter imbalance in the brain. Gradual tapering stabilizes serotonin, preventing withdrawal, making this critical teaching for safe medication management in anxiety treatment.

Choice B reason: Constipation is not a common side effect of fluoxetine, which primarily causes nausea or diarrhea via serotonin modulation. Anticholinergic drugs, not SSRIs, typically cause constipation. This teaching is inaccurate, as fluoxetine’s side effect profile does not emphasize gastrointestinal slowing, making it incorrect.

Choice C reason: Fluoxetine takes 4-8 weeks, not months, to reach efficacy by increasing serotonin in the prefrontal cortex and amygdala. Overstating the timeline discourages adherence, as patients expect faster relief from anxiety symptoms, making this teaching point scientifically inaccurate and misleading.

Choice D reason: Fluoxetine is not addictive, as it lacks the reinforcing GABA effects of benzodiazepines. It modulates serotonin for anxiety without dependence risk. This teaching is incorrect, as it misrepresents fluoxetine’s pharmacological profile, potentially causing unnecessary fear about its safe use in treatment.

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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

Correct Answer is D

Explanation

After a client has been prescribed fluoxetine (Prozac) for a diagnosis of anxiety disorder, which of the following information should the nurse be sure to include in the client teaching?

Correct Answer is A

Explanation

The spouse of a patient who experiences delusions asks the nurse, “Are there any circumstances under which the treatment team is justified in violating the patient’s right to confidentiality?” What is the nurse’s best response?

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