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: Suppressing anger ignores countertransference, which can impair therapeutic neutrality. Anger may stem from patient behaviors linked to dopamine-driven paranoia, but suppression risks unconscious bias affecting care. Addressing feelings through supervision maintains professionalism, making this response less effective for managing emotions.

Choice B reason: Discussing anger with a manager addresses countertransference, a reaction to patient behaviors like suspicion from dopamine dysregulation. This allows reflection, reducing bias and maintaining therapeutic neutrality. It supports professional care by processing emotions, aligning with evidence-based psychiatric nursing practices for managing countertransference.

Choice C reason: Expressing anger directly risks damaging the therapeutic alliance. Suspicion, tied to mesolimbic dopamine excess, may escalate with confrontation, increasing patient anxiety. This approach disregards professional boundaries and neurobiological sensitivities, making it inappropriate for maintaining effective psychiatric care.

Choice D reason: Reassigning the patient avoids addressing countertransference, neglecting professional growth. Suspicion, linked to neurobiological paranoia, requires consistent care. Reassignment disrupts continuity, potentially worsening patient trust and outcomes, making this an ineffective response compared to processing feelings through supervision.

A. Intervening when a self-mutilating patient attempts to harm self B. Exploring alternative options with a patient regarding medications C. Suggesting that two patients who are fighting be restricted to the unit D. Staying with a patient who is demonstrating a high level of anxiety

Correct Answer is B

Explanation

Choice A reason: Intervening in self-harm prioritizes beneficence, ensuring safety, over autonomy. Self-mutilation, often linked to dysregulated serotonin or impulsivity, requires immediate action to prevent harm, overriding patient choice. Autonomy is secondary when safety is at risk, making this an incorrect application of the principle.

Choice B reason: Exploring medication options respects autonomy by involving patients in decisions, aligning with their values. This considers individual neurobiological responses (e.g., serotonin reuptake variations) and preferences, empowering informed choice. Autonomy emphasizes patient control over treatment, making this the correct approach for ethical psychiatric care.

Choice C reason: Restricting patients for fighting prioritizes safety and unit order, not autonomy. Conflict may stem from emotional dysregulation or neurotransmitter imbalances, but restricting movement limits patient choice. This action reflects beneficence or justice, not autonomy, making it an incorrect choice for this ethical principle.

Choice D reason: Staying with an anxious patient supports emotional regulation, possibly linked to GABA deficits, but emphasizes beneficence over autonomy. While supportive, it does not involve patient decision-making. Autonomy requires empowering patient choice, not just presence, making this an incorrect application of the ethical principle.

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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 nurse caring for a withdrawn, suspicious patient recognizes the development of feelings of anger toward the patient. What is the nurse’s best response to these feelings?

Correct Answer is B

Explanation

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

Correct Answer is B

Explanation

The nursing student understands that the purpose of completing a process recording for the nurse-patient interview is to:

A patient reports experiencing performance anxiety in front of an audience. The nurse should be aware that this type of anxiety is often treated with which medication?

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?

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?

Which medication would be considered a first-line medication therapy for generalized anxiety disorder (GAD)?

A single parent is experiencing feelings of inadequacy related to work and family since one teenaged child ran away several weeks ago. The parent seeks the help of a therapist specializing in cognitive therapy. What intervention will the psychotherapist introduce?

A client is newly prescribed a medication that will block the effects of histamine for the treatment of a mental health disorder. The client asks, “What side effects should I anticipate with this new medication?” Which response by the nurse is accurate?