The nurse is planning care for a patient with mental illness. ...

[skymedlock]

The nurse is planning care for a patient with mental illness. What is true regarding patient goals?
 
  1. They should be clear and general.
  2. They should be general and open-ended.
  3. They should be concrete and measurable.
  4. They should be universal and standard.

Question 2

The nurse is caring for a patient with schizophrenia who is experiencing auditory hallucinations. The patient tells the nurse, The voices in my head are telling me to do things that I don't want to do.
 
  When planning care for this patient, what is the priority nursing diagnosis that the nurse will formulate?
  1. Risk for violence caused by schizophrenia, manifested by command hallucinations.
  2. Risk for violence due to auditory hallucinations, as evidenced by command hallucinations.
  3. Disturbed thought processes due to schizophrenia, as evidenced by command hallucinations.
  4. Disturbed thought processes due to auditory hallucinations, manifested by command hallucinations.

[mcarey591]

Answer to Question 1

Answer: 3
Explanation: Goals and outcomes are mutually-agreed upon with the patient and nurse. These goals should be concrete and measurable, in order to track progress. While goals should be clear and detailed, they should not be open-ended, general, or standard.

Answer to Question 2

Answer: 2
Explanation: The priority nursing diagnosis is risk for violence due to auditory hallucinations, as evidenced by command hallucinations. The patient who is having command auditory hallucinations is also experiencing disturbed thought processes; however, this is not the priority nursing diagnosis. All nursing diagnoses are formulated the same way: A problem is identified, and the words due to are used, followed by the causative agent. The words as evidenced by are then used, followed by the patient's manifestations or presenting symptoms.

[skymedlock]

TYSM

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