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

A patient's nursing diagnosis is Insomnia.The desired outcome is: "Patient will sleep for a minimum of 5 hours nightly by October 31." On November 1,a review of the sleep data shows the patient sleeps an average of 4 hours nightly and takes a 2-hour afternoon nap.Which evaluation should be documented?

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 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 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?

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.

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

The acronym QSEN refers to:

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

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

A patient's nursing diagnosis is Insomnia.The desired outcome is: "Patient will sleep for a minimum of 5 hours nightly by October 31." On November 1,a review of the sleep data shows the patient sleeps an average of 4 hours nightly and takes a 2-hour afternoon nap.What is the nurse's next action?

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

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 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?

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

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.

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

A newly admitted patient with major depression 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.

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.

When a nurse assesses an older adult 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:

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: