Exam 7: Nursing Process and QSEN: The Foundation for Safe and Effective Care

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.)

A patient states, "I'm not worth anything. I have negative thoughts about myself. I feel anxious and shaky all the time. Sometimes I feel so sad that I want to go to sleep and never wake up." Which nursing intervention should have the highest priority?

A nurse assesses an older adult patient brought to the emergency department by a family member. The patient was wandering outside, saying, "I can't find my way home." The patient is confused and unable to answer questions. Select the nurse's best action.

At one point in an assessment interview a nurse asks, "How does your faith help you in stressful situations?" This question would be asked during the assessment of:

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

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.

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

A newly admitted patient diagnosed with major depressive disorder has lost 20 pounds over the past month and has suicidal ideation. The patient has taken an antidepressant medication for 1 week without remission of symptoms. Select the priority nursing diagnosis.

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?

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

A patient diagnosed with major depressive disorder has lost 20 pounds in one month. The patient has chronic low self-esteem and a plan for suicide. The patient has taken an antidepressant medication for 1 week. Which nursing intervention is most directly related to this priority: "Patient will refrain from gestures and attempts to harm self"?

Which entry in the medical record best meets the requirement for problem-oriented charting?

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

Which statement made by a patient during an initial assessment interview should serve as the priority focus for the plan of care?

The acronym QSEN refers to:

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

A nurse assesses a patient who reluctantly participates in activities, answers questions with minimal responses, and rarely makes eye contact. What information should be included when documenting the assessment? (Select all that apply.)

When a new patient is hospitalized, a nurse takes the patient on a tour, explains the rules of the unit, and discusses the daily schedule. The nurse is engaged in:

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:

When a nurse assesses an older adult patient, the patient's 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: