Question 1

To best facilitate interdisciplinary communication regarding the plan of care for a patient diagnosed with paranoid schizophrenia,the nurse:

Accepted Answer

The Nursing Interventions Classification (NIC)is the first comprehensive standardized classification of interventions.The NIC states that one should not change intervention labels and definitions so that there is no confusion across settings.Although not inappropriate,the remaining options do not directly minimize confusion related to communication.

Question 2

The nurse responsible for the care plan of a patient diagnosed with cognitive impairment includes rationales for the nursing interventions primarily to:

Accepted Answer

Rationales primarily reflect nurses' accountability for their actions by explaining why the action is necessary and expected to positively impact the patient's condition.Rationales are not used to support or evaluate the success of the intervention nor to educate how the action should be preformed.

Question 3

A benefit of the implementation of clinical pathways is evidenced when the patient states:

Accepted Answer

Clinical pathways are tools that among other things promote interdisciplinary care thus providing for holistic care of the patient.The remaining options do not involve the additional recognized benefits of clinical pathways that include cost effectiveness and access to patient status reports.

Question 4

A nurse shows effective critical thinking skills directed towards nursing care of a cognitively impaired patient who continues to socially isolate by:

Accepted Answer

Critical thinking in this case involves the creation of alternative solutions to a problem that was not resolved by conventional methods.The remaining options,although not inappropriate,do not show critical thinking skills

Question 5

While discussing assessment of suicidal patients,a novice nurse mentions,"I was taught to always base my care on concrete,evidence-based scientific reasoning and never to rely on intuition." Which response by the experienced nurse shows understanding of intuitive reasoning?

Accepted Answer

A "strong hunch" or a "gut feeling" is an example of intuitive reasoning that is believed to come from the therapeutic relationship's sharing of feelings between nurse and patient.Most nurses agree that intuition is compatible with scientific reasoning,because both are likely linked to practice and experience.A nurse learns intuitive reasoning through clinical practice rather than from school or books.

Question 6

A nurse best shows an understanding of the role of evidence-based research in achieving therapeutic patient care outcomes when:

Accepted Answer

Evidence-based practice is based on evidence and scientific principles that have been developed through research.The more closely clinical practice reflects relevant research,the more likely it is that patients will receive the best available care.The option that infers action directed at implementing the research is the one that shows best understanding.Reliance only on experience is not reflective of quality nursing care.

Question 7

The nurse best fulfills the obligation to be accountable for providing care that meets the expected standards of care when:

Accepted Answer

Evaluation of the patient's progress and the nursing activities involved are critical because nurses are accountable for the standards of care in each discipline.Although the other options reflect appropriate and expected nursing interventions,they are not the primary means of assuring that standard of care has been met.

Question 8

When a patient experiencing acute depression asks what the difference is between a medical and a nursing diagnosis,the nurse responds best when stating:

Accepted Answer

The medical diagnosis involves identifying a mental or physical problem that results in the symptoms that negatively affect a patient's life.Although the nurse is knowledgeable about the disorders and their treatments,the nursing diagnosis focuses mainly on the patient's responses to the disorder and the effects that the disorder has on the patient.The types of diagnoses have different foci that result in different actions and concerns.

Question 9

A patient who has a nursing diagnosis of ineffective coping related to ineffective problem solving has been involved in treatment for 6 months.The nurse determines that the planned interventions require revision when the patient states:

Accepted Answer

Nursing interventions describe a specific course of action or a therapeutic activity that helps the patient to move toward a more functional state; in this case problem solving.The statement indicates indecision and suggests that problem solving is still a patient problem.Showing dislike of the physician actually shows a decision.Not accepting the realization of ineffective decision making is not related to ineffective coping but rather shows focus on affecting the problem.Expressing the perception that one is not liked concerns self-esteem.

Question 10

The nurse shows an understanding of the appropriate use of nursing outcomes regarding triggers for a patient diagnosed with chronic alcohol abuse when stating:

Accepted Answer

Outcomes sometimes referred to as behavioral goals are used to describe and evaluate the effectiveness of nursing interventions.The correct option shows that the patient was successful at accomplishing an outcome inferring the nursing interventions were successful.The remaining options do not indicate an evaluation of success or failure.

Question 11

When reviewing the history of a newly admitted patient diagnosed with severe chronic depression,the nurse is most concerned about patient safety issues when noting:

Accepted Answer

The Global Assessment of Functioning (GAF)Scale is one of the tools use to assess patient functioning and possible prognosis.It is coded on a numerical continuum,with 1 indicating little danger and 10 indicating severe or persistent danger,and possible suicidal potential.Mental deficiency may contribute to issues of safety but it is not a significant risk factor.Noncompliance may contribute to the patient's depression but it is not the greatest concern identified.Although past history is considered a predictor of future behavior,this is more related to the safety of others than to the patient.

Question 12

When engaging in outcomes identification,the nurse:

Accepted Answer

Outcomes are projections of expected influence that nursing interventions will have on the patient.Interviewing and collecting data is involved in the assessment process,re-assessing is involved in the evaluation process,and identifying related nursing problems is involved in determining appropriate nursing diagnoses.

Question 13

The patient asks the nurse,"I've heard the student nurses talk about the nursing process.Why is there so much emphasis on using the nursing process?" The response that explains the need for nurses to understand and use the nursing process is:

Accepted Answer

This response best explains the importance of the nursing process by description and relationship to patient care.Suggesting that the patient may have a better method is challenging and does not address the question posed by the patient.Providing legitimacy to the profession is a very limited explanation for use of the nursing process.The nursing process is not one-dimensional,static,or linear.

Question 14

When caring for a patient admitted with a diagnosis if bipolar disorder,managed care regulations is the driving force behind the nurse's use of:

Accepted Answer

Managed care regulations have brought about the use of clinical pathways (also called critical pathways or a care maps)which are standardized multidisciplinary planning tools that monitor patient care through projected caregiver interventions and expected patient outcomes with a projected timeline of success.NANDA nursing diagnoses are not related to regulations or payment concerns.The implementation of short-term stress management therapy in an acute care psychiatric environment would not be driven by managed care regulation or payment concerns.The use of generic medications when appropriate is primarily cost driven.

Question 15

The nurse assesses a patient's judgment by asking:

Accepted Answer

Judgment is the ability to assess and evaluate situations,make rational decisions,understand consequences of behavior,and take responsibility for actions.Judgment may be assessed by asking a question that has a common-sense answer.The other options ask about motivation,elicits historical information about the illness or seeks information about insight.

Question 16

The nurse shows the ability to effectively state a nursing diagnosis reflective of the implications of depression on a patient's life processes when stating in the patient's plan of care that:

Accepted Answer

This statement contains the various components of a nursing diagnosis while expressing the existence of an altered life process.The remaining options reflect other steps,such as evaluation and intervention planning.

Question 17

When preparing to conduct a nursing history and assessment on a patient transferred from the emergency department (ED)whose family believes the patient to be a questionable historian due to cognitive impairment,the nurse initially begins the interview by:

Accepted Answer

The nurse should begin establishing the nurse-patient relationship by initially directing the questions to the patient.The nurse can confirm information and/or obtain supplementary information from the sources identified by the other options.

Question 18

A depressed patient shares with the nurse that he,"has been thinking about ending it all".Based on NANDA recommendations,the nurse:

Accepted Answer

NANDA states that a nurse is able to change any actual diagnosis on the NANDA list to a risk diagnosis if the problem has not occurred yet.The remaining options,although not inappropriate,do not related to NANDA.

Question 19

A nurse shows the best understanding of the legal importance of the patient's chart when stating:

Accepted Answer

The patient's chart is a legal document that effectively communicates patient outcomes,medications,treatments,responses,and unusual incidents reflecting the healthcare systems attempts at meet the standard of care appropriate for this patient.The other options are not as inclusive in describing the legal status of the chart.

Question 20

An appropriate nursing diagnosis for a patient who manifests a psychological problem through frequent expressions of unfounded or excessive guilt or shame,states that he is unable to deal with situations,and has a hesitation to try new things would be:

Accepted Answer

The behaviors mentioned in the situation are congruent with criteria for the diagnosis of chronic low self-esteem.The patient's symptoms go beyond powerlessness.Hopelessness does not involve feelings of guilt and shame.The data is not consistent with a diagnosis of ineffective coping.

Quiz 3: The Nursing Process and Standards of Care