A staff nurse completes orientation to a psychiatric unit. This nurse should expect to perform which of the following interventions?(Select All that Apply.)
Prescribe psychotropic medications.
Establish the client's diagnosis.
Establish the client's goals.
Individualize nursing care plans.
Establish therapeutic relationships.
Conduct mental health assessments.
Correct Answer : C,D,E,F
Choice A reason: Prescribing medications is outside the scope of practice for nurses. This is the responsibility of licensed prescribers such as physicians or nurse practitioners.
Choice B reason: Establishing a formal psychiatric diagnosis is the role of providers with diagnostic authority. Nurses contribute to assessment but do not independently diagnose.
Choice C reason: Nurses collaborate with clients to establish individualized goals. This empowers clients and ensures care is client-centered.
Choice D reason: Nurses tailor care plans to meet each client’s unique needs. Individualization ensures interventions are appropriate and effective.
Choice E reason: Establishing therapeutic relationships is a core nursing role in psychiatric care. It fosters trust, engagement, and adherence to treatment.
Choice F reason: Conducting mental health assessments is within the nurse’s scope. Nurses gather data on mood, affect, thought processes, and behavior to inform care planning.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: The priority is to assess the content of the hallucinations to determine the level of risk. If the voices are commanding self-harm or violence, immediate safety interventions are required. This makes assessment the first and most critical step.
Choice B reason: Reminding the client that the voices are not real may be therapeutic later, but it does not address the immediate safety concern. Without knowing the content of the hallucinations, the nurse cannot determine risk.
Choice C reason: Escorting the client to a quiet room and encouraging relaxation may help reduce anxiety but does not address the potential danger of command hallucinations. Safety assessment must come first.
Choice D reason: Notifying the provider and requesting medication adjustment is appropriate after assessing the hallucination content. Immediate risk must be evaluated before treatment changes are considered.
Correct Answer is D
Explanation
Choice A reason: Asking “why” is not therapeutic. It may increase anxiety and does not provide support or safety. Clients with hallucinations need direct, supportive communication.
Choice B reason: Telling the client to command the voices may increase distress and is not therapeutic. It does not assess risk or provide safety.
Choice C reason: Denying the client’s experience by saying there are no voices invalidates their reality. This can increase mistrust and anxiety.
Choice D reason: Asking what the voices are saying allows the nurse to assess risk, especially if the voices are commanding harmful actions. It validates the client’s feelings while gathering critical safety information. This is the most therapeutic response.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.