Question 1

As a nurse assesses an elderly patient,answers seem vague or unrelated to the questions.The patient also leans forward and frowns,listening intently to the nurse.An appropriate question for the nurse to ask would be:

Accepted Answer

The patient's behaviors may indicate difficulty hearing.Identifying any physical need the patient may have at the onset of the interview and making accommodations are important considerations.

Question 2

A nurse asks a patient,"If you had fever and vomiting for 3 days,what would you do?" Which aspect of the mental status examination is the nurse assessing?

Accepted Answer

Assessing cognition involves determining a patient's judgment and decision making.In this case,the nurse would expect a response of "Call my doctor" if the patient's cognition and judgment are intact.If the patient responds,"I would stop eating" or "I would just wait and see what happened," the nurse would conclude that the judgment was impaired.The other options refer to other aspects of the examination.

Question 3

Which nursing documentation best meets the requirement for problem-oriented charting?

Accepted Answer

Problem-oriented documentation uses the first letter of key words to organize data: S for subjective data,O for objective data,A for assessment,P for plan,I for intervention,and E for evaluation.The distracters use PIE,focus,and narrative documentation.

Question 4

A patient begins a new program to assist with building social skills.In which part of the plan of care should a nurse record this item?
Encourage patient to attend one psychoeducational group daily.

Accepted Answer

In the nursing process,implementation is guided by the Psychiatric-Mental Health Nursing: Scope and Standards of Practice,which identifies seven areas for intervention.Interventions are the nursing prescriptions to achieve the outcomes and should be specific.

Question 5

A patient states: "I'm not worth anything.I have negative thoughts about myself.I want to go to sleep and never wake up." Which nursing intervention has the highest priority?

Accepted Answer

The nurse would place a priority on monitoring and reinforcing suicide self-restraint because it relates directly and immediately to patient safety.Patient safety is always a priority concern.The nurse would also be expected to monitor and reinforce all patient attempts to control anxiety,improve sleep patterns,and develop self-esteem while giving priority attention to suicide self-restraint.

Question 6

Complete this nursing diagnosis: ___________ related to shyness and poorly developed social skills as evidenced by watching television alone at home every evening.

Accepted Answer

Nursing diagnoses are selected based on the etiological factors and assessment findings or evidence.In this instance,the evidence shows social isolation which is caused by shyness and poorly developed social skills.

Question 7

Nursing behaviors associated with the implementation phase of the nursing process are concerned with:

Accepted Answer

Nursing behaviors relating to implementation include considering available resources,performing care-giving interventions,finding alternatives when necessary,and coordinating care with other team members.

Question 8

Before assessing a new patient,a nurse is told by another health care worker,"I know that patient.No matter how hard we work,there isn't much improvement by the time of discharge." The nurse's responsibility is to:

Accepted Answer

Assessment should include data obtained from both the primary and reliable secondary sources.Biased assessments by others should be evaluated as objectively as possible by the nurse.

Question 9

A patient's nursing diagnosis is sleep-pattern disturbance.The desired outcome is: Patient will sleep for a minimum of 5 hours nightly by October 31.On November 1,review of sleep data for 6 days shows the patient slept an average of 4 hours nightly and took 2-hour afternoon naps daily.Which evaluation should be documented?

Accepted Answer

Although the patient is sleeping 6 hours daily,uninterrupted sleep was not achieved.Therefore,the outcome was never demonstrated.

Question 10

A nurse works with a patient to establish outcomes but believes that one outcome suggested by the patient is not in the patient's best interests.What is the nurse's best action?

Accepted Answer

The nurse should not impose outcomes on the patient;however,the nurse has a responsibility to help the patient evaluate what is in his or her best interests.Exploring possible consequences is an acceptable approach.

Question 11

An adult patient recently diagnosed with cancer states,"I've lived my life according to the Bible.I don't understand why God has forsaken me." Which nursing diagnosis applies?

Accepted Answer

The patient is experiencing distress rather than dysfunction related to spirituality.

Question 12

A nurse assessing a new patient asks,"What is meant by the old saying,'You can't judge a book by looking at the cover'?" Which aspect of cognition is the nurse assessing?

Accepted Answer

Interpretation of proverbs gives assessment information regarding the patient's ability to abstract,which is an aspect of cognition.

Question 13

A newly admitted patient is severely depressed,lost 20 pounds over the past month,and expresses hopelessness for the future.Select the priority nursing diagnosis.

Accepted Answer

Risk for suicide is the priority diagnosis when the patient has vegetative symptoms of depression and no hope for the future.Imbalanced nutrition,powerlessness,and chronic low self-esteem may be applicable nursing diagnoses,but these problems do not affect patient safety as urgently as would a suicide attempt.

Question 14

An adolescent asks the nurse,"Why should I tell you anything? You'll just tell my parents whatever you find out." Select the nurse's best reply.

Accepted Answer

The patient has a right to know that most information is held in confidence but that certain material must be reported or shared with the treatment team,such as threats of suicide,homicide,use of illegal drugs,or issues of abuse.

Question 15

Which statement made by a patient should serve as the priority focus for the plan of care?

Accepted Answer

The correct response indicates that the patient may be experiencing auditory hallucinations.The other statements are significant but require additional exploration.

Question 16

A nurse assesses an elderly patient brought to the emergency department by a grandchild who found the patient wandering in the front yard saying,"I can't find my way home." The patient is confused and unable to answer questions.Select the nurse's next action.

Accepted Answer

When the patient (primary source)is unable to provide information,secondary sources should be used,in this case the granddaughter.Later,more data may be obtained from other relatives or neighbors who are familiar with the patient.

Question 17

At what point in an assessment interview could a nurse logically ask,"How does your faith help you in stressful situations?" During the assessment of:

Accepted Answer

When discussing coping strategies,the nurse might ask what the patient does when he or she becomes upset,what usually relieves stress,and to whom the patient goes to talk about problems.The question regarding whether the patient's faith helps deal with stress fits well here.It would seem out of place if introduced during exploration of the other topics.

Question 18

A severely depressed patient lost 20 pounds over the past month,has chronic low self-esteem,and the intent and a plan for suicide.The patient has taken an antidepressant medication for 1 week.The nurse adds this outcome to the plan of care: Patient will refrain from gestures and attempts to harm self.Which nursing intervention is most directly related to this outcome?

Accepted Answer

The intervention should relate to patient safety.The other options,related to nutrition,self-esteem and medication therapy,are important but not a priority.

Question 19

Select the best outcome for a patient with this nursing diagnosis: Impaired social interaction related to sociocultural dissonance as evidenced by stating,"Although I'd like to,I don't join in because I don't speak the language very well." Within 1 week,the patient will:

Accepted Answer

The outcome describes social involvement on the part of the patient.Outcomes should be clearly measurable.Neither cooperation nor independence has been an issue.The patient has already expressed a desire to interact with others.

Question 20

During an initial assessment,a patient becomes anxious and evasive when the nurse asks,"Have you ever heard voices when no one else was around?" The patient asks,"Why do you need to know that?" Select the nurse's best response.

Accepted Answer

The nurse should not try to pry information out of a patient who is reluctant to give the information.The nurse should note the patient's reaction to the question and carefully observe for behavioral signs that the patient may be experiencing auditory hallucinations.

Quiz 8: The Nursing Process and Standards of Care for Psychiatric Mental Health Nursing