Question 1

Assessment findings by the multidisciplinary team after a patient-intake interview are used primarily for what purpose?

Accepted Answer

Assessment findings by the multidisciplinary team after a patient-intake interview are primarily used to expand and confirm the initial assessment. This helps to ensure that all aspects of the patient's condition have been considered and that an accurate diagnosis and appropriate plan of care are developed. It may also identify additional needs that require further assessment or interventions. Confirmation of ongoing discharge planning, verification of nursing diagnoses, and analysis of the patient's feelings about hospitalization may also be part of the process, but these are secondary to expanding and confirming the initial assessment.

Question 2

As the nurse plans care for a newly admitted patient, identification of dysfunctional behaviors will provide the focus for which component of the nursing process?

Accepted Answer

The answer of As the nurse plans care for a...

Question 3

The nurse performing a mental status examination wants to assess for hallucinations. The nurse should ask which question?

Accepted Answer

The answer of The nurse performing a mental status examination...

Question 4

What fact about a particular patient will have the greatest impact on nurse-patient collaboration?

Accepted Answer

The answer of What fact about a particular patient will...

Question 5

The nurse writing a discharge summary for a patient should include achievements as well as what additional information?

Accepted Answer

The answer of The nurse writing a discharge summary for...

Question 6

A student states, "I do not see the value of process recordings." The response to this concern should be based on what information related to process recording?

Accepted Answer

Process recordings are a tool for analyzing communication. They allow the student to reflect on their interaction with the patient, identify areas for improvement, and develop better communication skills. They are not a legal document or a verbatim record of the interview, and they are not necessarily written to provide information to team members.

Question 7

When the nurse formulates nursing diagnoses, it is necessary to be specific in describing dysfunctional behaviors so as to demonstrate what desired outcome?

Accepted Answer

By being specific in describing dysfunctional behaviors, the nurse is able to identify the exact problem that needs to be addressed and can select appropriate desirable behaviors that will promote healing and improve the patient's overall health outcomes. This helps to guide the nursing interventions and establish clear goals for the patient's care.

Question 8

What is a realistic time frame for achievement of short-term goals for a patient who is newly admitted to the hospital?

Accepted Answer

Short-term goals for a patient newly admitted to the hospital are typically aimed to be achieved within a few days to a week, making 4 to 6 days a realistic time frame. This allows for immediate care needs to be addressed and for any necessary adjustments to treatment plans based on the patient's response.

Question 9

Objective data obtained from family in an initial assessment of a patient are of particular value when which situation exists?

Accepted Answer

Objective data obtained from family members are especially important when the patient is too ill to participate in the assessment. In this situation, the family can provide valuable information about the patient's medical history, symptoms, and behaviors.

Question 10

What activity would be involved in achieving an appropriate short-term goal for a patient diagnosed with situational low self-esteem?

Accepted Answer

The answer of What activity would be involved in achieving...

Question 11

A psychotic patient tells the nurse, "Get away from me or I'll hit you. You're sucking the thoughts out of my head." To best de-escalate the situation, what intervention should the nurse implement?

Accepted Answer

The primary concern in this situation is the safety of both the patient and the nurse. Increasing the distance between them can help prevent any physical harm. Directing the patient to a chair may not be effective as the patient is already exhibiting signs of aggression. Denying taking the patient's thoughts may increase the patient's paranoia and hostility. Threatening the patient with restraint may escalate the situation and increase the patient's agitation.

Question 12

Following the admission interview, a spouse of a patient asks the nurse, "Why did you ask my partner all those questions? Some of them had nothing to do with the current problems." The nurse's best response is based on what assessment focus of the mental status examination (MSE)?

Accepted Answer

The focus of the mental status examination (MSE) is to assess the patient's current status, including their cognitive functioning, mood, and behavior. The questions asked during the interview are designed to gather information about these areas, as well as any relevant medical or psychiatric history. While some questions may not seem directly related to the patient's current problems, they may provide important information about overall mental functioning and potential contributing factors to their presenting problems.

Question 13

During a mental status examination (MSE) a patient says, "I am a special messenger sent to provide the world a cure for cancer." The patient's statement indicates the presence of what form of dysfunctional thought content?

Accepted Answer

The patient's statement indicates a belief in something that has no basis in reality, which is a characteristic of a delusion. A phobia is an intense and irrational fear of a specific object or situation, hypervigilance is excessive alertness and scanning of the environment, and loose associations refer to a disturbance in the organization and coherence of thoughts.

Question 14

What is the most effective outcome for a nurse to include in the care plan for a withdrawn patient who says, "I would like to have more friends"? Within 3 days:

Accepted Answer

Participating in one group activity is a specific, measurable, achievable, relevant, and time-bound (SMART) goal that directly addresses the patient's expressed desire to have more friends, making it the most effective outcome to include in the care plan.

Question 15

A patient with suicidal ideation is hospitalized. What is the priority intervention?

Accepted Answer

The priority intervention for a patient with suicidal ideation is to ensure their safety. Negotiating a no-harm contract with the patient is a crucial step in ensuring that they do not harm themselves while hospitalized. This contract outlines the patient's commitment to not engage in any self-harm behaviors and encourages them to seek help if they have any suicidal thoughts. Once safety is established, other interventions can be implemented, such as group attendance, medication, and determining the precipitating situation.

Question 16

A patient hospitalized for 6 days has made little progress toward outcomes written at the time of admission. The nurse decides that the lack of progress toward goals indicates a need for what intervention?

Accepted Answer

A reassessment of the patient's condition and current care plan is needed to determine if revisions to the plan are necessary to achieve the desired outcomes. Delaying discharge, assuming the patient is stable enough to be discharged, would not address the lack of progress. Incorrect nursing diagnoses or inaccurate interventions are possible causes for lack of progress, but a reassessment is necessary to determine if these are the root causes.

Question 17

A nurse considers interventions for a diabetic patient who needs to change eating habits and lose weight. The nurse will base strategies on which principle?

Accepted Answer

Patient-initiated change is more successful than imposed change. When patients are involved in their own care and decision-making, they are more likely to be committed and adherent to the plan. The nurse can support the patient in making their own choices and setting realistic goals.

Question 18

A psychiatric aide asks, "Can you give me some examples of how we provide structure for patients?" The nurse should offer which suggestions? (Select all that apply.)

Accepted Answer

Setting limits on destructive behavior, directing patients to quiet places, sitting with withdrawn patients, and distracting those who are hallucinating are all ways to provide structure and support in a psychiatric setting. These actions help manage symptoms and promote a safe environment. Contemplating needed change is more related to therapy and long-term treatment planning rather than immediate structure.

Question 19

The nurse caring for a hyperactive patient should identify what assessment as being the priority?

Accepted Answer

The priority assessment for a hyperactive patient is physical safety as their behavior can put themselves and others at risk. Once physical safety is ensured, the nurse can address other assessments such as emotional trauma and manipulative behaviors. Feelings about the relationship may not be a priority assessment in this situation.

Question 20

A patient tells the nurse, "I was raped a month ago. Since then I've felt anxious and have been unable to talk normally to my husband. I've had frequent thoughts about cutting my wrists." What is the priority nursing concern regarding this patient?

Accepted Answer

The patient's statement about cutting her wrists indicates a high risk for self-directed violence and must be the priority nursing concern. The nurse should assess the patient's suicide risk and implement appropriate interventions to ensure her safety. The development of rape traumatic syndrome, damage to self-esteem, and signs of anxiety are important concerns as well, but they are not as immediately life-threatening as self-harm.

Quiz 9: Working With an Individual Patient