A nurse is interviewing a client who is experiencing negative symptoms of psychosis about their family history of schizophrenia. In which of the following phases of the nursing process should this take place?
Implementation
Evaluation
Assessment
Planning
The Correct Answer is C
Choice A reason:
Implementation involves carrying out the interventions outlined in the care plan. This phase focuses on executing the planned actions to achieve the desired outcomes and does not include gathering initial information about the client’s history.
Choice B reason:
Evaluation involves assessing the effectiveness of the interventions and determining whether the goals of the care plan have been met. This phase occurs after the initial assessment and implementation of interventions.
Choice C reason:
Assessment is the first phase of the nursing process, where the nurse gathers comprehensive information about the client’s health status, including their family history of schizophrenia. This information is crucial for developing an accurate diagnosis and care plan.
Choice D reason:
Planning involves setting goals and determining the appropriate interventions based on the assessment data. While planning is essential, it follows the assessment phase and relies on the information gathered during the assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
Choice A reason:
An electroencephalogram (EEG) monitor is essential for monitoring the brain’s electrical activity during ECT. This equipment helps ensure that the treatment is administered safely and effectively by providing real-time data on the patient’s brain waves. The EEG monitor is crucial for assessing the patient’s response to the therapy and detecting any abnormalities.
Choice B reason:
An ophthalmoscope is used to examine the interior structures of the eyes, which is not relevant to the ECT procedure. Therefore, it is not necessary to set up an ophthalmoscope in the room prior to ECT. The focus of ECT preparation is on monitoring the patient’s neurological and cardiovascular status, not on eye examinations.
Choice C reason:
A cardiac monitor is vital for tracking the patient’s heart rate and rhythm during ECT. This equipment helps detect any cardiac abnormalities or arrhythmias that may occur as a result of the treatment. Continuous cardiac monitoring ensures that any potential complications can be promptly addressed, making it an essential piece of equipment for ECT.
Choice D reason:
A blood pressure monitor is necessary for measuring the patient’s blood pressure before, during, and after the ECT procedure. Monitoring blood pressure is crucial for detecting any significant changes that could indicate cardiovascular stress or other complications. This equipment helps ensure the patient’s safety throughout the treatment.
Choice E reason:
A portable X-ray machine is not required for ECT. X-rays are used for imaging purposes, which are not part of the standard ECT procedure. The primary focus during ECT is on monitoring the patient’s neurological and cardiovascular status, making the portable X-ray machine unnecessary for this context.
Correct Answer is D
Explanation
Choice A reason:
Developmental theories focus on the progression of human growth and development through various stages of life. While these theories are important in understanding patient behavior and needs, they do not directly relate to the implementation of a privilege system in an inpatient unit. Privilege systems are more aligned with behavioral theories, which emphasize the modification of behavior through reinforcement and consequences.
Choice B reason:
Humanistic theories emphasize the individual’s capacity for self-actualization and personal growth. These theories focus on the holistic development of the person and the importance of empathy and unconditional positive regard in therapeutic relationships. Although humanistic approaches are valuable in mental health care, they do not specifically address the structured reinforcement strategies used in privilege systems.
Choice C reason:
Cognitive theories focus on the role of thought processes in influencing emotions and behaviors. These theories are crucial in understanding and treating mental health conditions, particularly through cognitive-behavioral therapy (CBT). However, the privilege system, which relies on tangible rewards and consequences to shape behavior, is more closely related to behavioral theories rather than cognitive ones.
Choice D reason:
Behavioral theories are directly related to the use of a privilege system. These theories emphasize the use of reinforcement and punishment to modify behavior. In an inpatient setting, a privilege system is used to encourage desirable behaviors by providing rewards (privileges) and discouraging undesirable behaviors through the removal of privileges. This approach is grounded in the principles of operant conditioning, a key concept in behavioral theories.
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