Question 1

A nurse prepares to assess a new patient who moved to the United States from Central America 3 years ago. After introductions, what is the nurse's next comment?

Accepted Answer

The nurse should determine whether a translator is needed by first assessing the patient for language barriers. Accuracy of the assessment depends on the ability to communicate in a language that is familiar to the patient. Family members are not always reliable translators. An interpreter may change the patient's responses; a translator is a better resource.

Question 2

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

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

Question 3

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? (Select all that apply.)

Accepted Answer

Both content and process of the interview should be documented. Providing only the patient's verbal responses would create a skewed picture of the patient. Writing that the patient was uncooperative is subjectively worded. An objective description of patient behavior would be preferable. Analysis of the reasons for the patient's behavior would be speculation, which is inappropriate.

Question 4

"QSEN" refers to

Accepted Answer

QSEN represents national initiatives centered on patient safety and quality. The primary goal of QSEN is to prepare future nurses with the knowledge, skills, and attitudes to increase the quality, care, and safety in the health care setting in which they work.

Question 5

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

This narrative note describes patient appearance, behavior, and conversation. It mentions that less-restrictive measures were attempted before administering medication and documents patient response to medication. This note would probably meet standards. A complete nursing assessment would be in order as soon as the patient is able to participate. Subjective material is absent from the note. Abbreviations are acceptable.

Question 6

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? (Select all that apply.)

Accepted Answer

During the assessment interview, the nurse should listen attentively and accept the patient's statements in a nonjudgmental way. Because the patient is suspicious and fearful, reassuring safety may be helpful, although trust is unlikely so early in the relationship. Saying that medication will help or telling the patient that the ideas are not realistic will undermine development of trust between the nurse and patient.

Question 7

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 defining characteristics are more related to the nursing diagnosis of impaired verbal communication than to the other nursing diagnoses.

Question 8

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 9

What information is conveyed by nursing diagnoses? (Select all that apply.)

Accepted Answer

Nursing diagnoses focus on phenomena of concern to nurses rather than on medical diagnoses.

Question 10

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? (Select all that apply.)

Accepted Answer

Standardized scales are useful for obtaining data about substance use disorders. The ASI, B-DAST, and RAATE are scales related to substance abuse. AIMS assesses involuntary movements associated with antipsychotic medications. The CCSE assesses cognitive function.

Quiz 7: The Nursing Process and Standards of Care