Question 1

A patient is very suspicious and states, "The FBI has me under surveillance." Which strategies should a nurse use when gathering initial assessment data about this patient?

Accepted Answer

The answer of A patient is very suspicious and states,...

Question 2

A nurse documents, "Patient is mute despite repeated efforts to elicit speech. Makes no eye contact. Inattentive to staff. Gazes off to the side or looks upward rather than at speaker." Which nursing diagnosis should be considered?

Accepted Answer

The patient is mute and not making eye contact or attending to staff, indicating an impairment in verbal communication. Defensive coping, decisional conflict, and risk for other-directed violence are not supported by the given information.

Question 3

A nurse prepares to assess a new patient who moved to Canada from Central America three years ago. After introductions, what is the nurse's next comment?

Accepted Answer

It is important to ensure effective communication by assessing the patient's language preference and comfort level in conversing in English, offering a translator if needed.

Question 4

A nurse performing an assessment interview for a patient with a substance use disorder decides to use a standardized rating scale. Which scales are appropriate?

Accepted Answer

The Addiction Severity Index (ASI), Brief Drug Abuse Screen Test (B-DAST), and Recovery Attitude and Treatment Evaluator (RAATE) are all appropriate scales for assessing substance use disorders. The ASI evaluates the severity of addiction, the B-DAST screens for drug abuse, and the RAATE assesses attitudes towards recovery and treatment.

Question 5

A nurse assessed a patient who reluctantly participated in activities, answered questions with minimal responses, and rarely made eye contact. What information should be included when documenting the assessment?

Accepted Answer

The answer of A nurse assessed a patient who reluctantly...

Question 6

The nurse records this entry in a patient's progress notes: Patient escorted to unit by ER nurse at 2130. Patient's clothing was dirty. In interview room, patient sat with hands over face, sobbing softly. Did not acknowledge nurse or reply to questions. After several minutes, abruptly arose, ran to window, and pounded. Shouted repeatedly, "Let me out of here." Verbal intervention unsuccessful. Order for stat dose 2 mg haloperidol PO obtained; medication administered at 2150. By 2215, patient stopped shouting and returned to sit wordlessly in chair. Patient placed on one-to-one observation. How should this documentation be evaluated?

Accepted Answer

The progress notes provide a clear and concise description of the patient's behavior and actions, as well as the nursing interventions that were taken to manage the situation. The documentation is objective and free of unapproved abbreviations, making it a valuable and professional record of the patient's care.

Question 7

Select the most appropriate label to complete this nursing diagnosis: ___________ related to feelings of shyness and poorly developed social skills as evidenced by watching television alone at home every evening.

Accepted Answer

The patient is isolating themselves at home every evening due to feelings of shyness and poorly developed social skills, indicating a diagnosis of social isolation. Choice A (deficient knowledge) does not fit the given information and choice B (ineffective coping) and D (powerlessness) do not accurately address the specific issue of social isolation.

Question 8

What does the nurse assess when completing the final "S" of the HEADSSS Psychosocial Interview Technique?

Accepted Answer

The answer of What does the nurse assess when completing...

Question 9

After formulating the nursing diagnoses for a new patient, what is a nurse's next action?

Accepted Answer

The third step of the nursing process is planning and outcome identification. Outcomes cannot be determined until the nursing assessment is complete and nursing diagnoses have been formulated.

Question 10

What information is conveyed by nursing diagnoses?

Accepted Answer

The answer of What information is conveyed by nursing diagnoses?
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Quiz 6: The Nursing Process and Standards of Care for Psychiatric Mental Health Nursing