a patient with agoraphobia reports that they havent left their house in months what is the most appropriate nursing diagnosis for this patient a patient with agoraphobia reports that they havent left their house in months what is the most appropriate nursing diagnosis for this patient
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Nursing Elites

ATI LPN

ATI Mental Health Practice A

1. What is the most appropriate nursing diagnosis for a patient with agoraphobia who reports not having left their house in months?

Correct answer: A

Rationale: The nursing diagnosis 'Social isolation' is most appropriate for a patient with agoraphobia who has not left their house in months. Agoraphobia often leads to the avoidance of situations or places perceived as unsafe, resulting in social isolation. This diagnosis reflects the patient's limited social interactions and confinement to the home environment, which can impact their overall well-being and mental health. The other options are not as relevant in this scenario: 'Ineffective coping' does not directly address the social withdrawal aspect, 'Risk for injury' is not the primary concern presented, and 'Impaired social interaction' does not capture the extent of isolation described.

2. Which tissue has the highest rate of protein turnover?

Correct answer: B

Rationale: The correct answer is B: Intestinal mucosa. The intestinal mucosa has the highest rate of protein turnover due to its rapid cell renewal. The skin, muscle, and adipose tissue do not exhibit protein turnover rates as high as the intestinal mucosa. Skin cells turnover relatively slower compared to the rapid renewal of intestinal mucosa cells. Muscles have a moderate rate of protein turnover, while adipose tissue has a lower turnover rate compared to the other tissues mentioned.

3. A nurse is providing discharge instructions to parents of a circumcised newborn. To prevent diaper adherence to the penis, what will be recommended to apply during diaper changes?

Correct answer: C

Rationale: Petroleum jelly is recommended to prevent the diaper from sticking to the circumcised area, reducing irritation and promoting healing. It should be applied during every diaper change until the site heals. Baby oil (Choice A) is not recommended as it may not provide a sufficient barrier to prevent adherence. Antibiotic ointment (Choice B) is not typically used for this purpose and can sometimes cause irritation. Alcohol wipes (Choice D) are too harsh for the sensitive skin of a newborn and can cause irritation.

4. To form a core support group of nurses, where should the nurse organizer conduct meetings to gather initial information?

Correct answer: B

Rationale: The correct approach is to conduct meetings in homes or local businesses with staff nurses. This location ensures confidentiality, prevents management influence, and allows the focus to be on gathering support for forming a core support group. Choice A is incorrect as involving managers may compromise the independence and authenticity of the group. Choice C is incorrect as conducting meetings at the facility may not provide a secure and unbiased environment for open discussions. Choice D is incorrect because holding meetings at the work site with respected leaders may lead to biased opinions and hinder open communication.

5. A nurse overhears two assistive personnel (APs) discussing a client in a hospital cafeteria, using the client’s name and discussing details of the diagnosis. Which of the following actions should the nurse take first?

Correct answer: D

Rationale: The correct action for the nurse to take first is to tell the APs to discontinue their conversation. By stopping the conversation immediately, the nurse addresses the breach of client confidentiality on the spot. This action is crucial to protect the client's privacy and confidentiality. While further steps such as reporting the behavior or providing education on confidentiality may be necessary, the immediate priority is to stop the inappropriate discussion. Reporting the behavior to the supervisor or completing an incident report can come after the immediate issue is addressed. Providing written documentation on confidentiality may be helpful but is not the most urgent action needed in this situation.

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