Answer to Question 1
Assessment, nursing diagnosis, planning, intervention, evaluation
The steps of the nursing process provide a means of addressing problems identified as affecting the client. Assessment is ongoing, the nursing diagnosis is the identification of client problems, and client goals are set during the planning phase. Interventions are determined, then implemented. Lastly, goals are evaluated to determine whether they have been met, partially met, or not met at all. In the latter two evaluation results if the goals have not been met or only partially met, the plan of care must be reevaluated and revised.
Answer to Question 2
C
The patient is expressing paranoid delusions. By definition, a delusion is a persistent irrational belief held despite evidence to the contrary. Therefore, stating that his belief is untrue will not make sense to him and may reinforce his belief that people are set against him. Similarly, because the delusion is believed firmly regardless of the evidence, providing more evidence that the belief is wrong or guiding the patient to look at the evidence are unlikely to be helpful and may reinforce his delusion. The most therapeutic response is the one which focuses on the feeling associated with the belief rather than the belief itself. It conveys empathy and interest in the patient's concerns, helping to build trust in the staff and giving him an opportunity to work through the fear he is experiencing.