Deck 3: The Nursing Process and Standards of Care

Question 1

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

A) Requires weekly meetings of the care team
B) Ensures the team includes members from all appropriate disciplines
C) Uses the standardized NIC classification system of care interventions
D) Recognizes the need for team access to patient records and makes them available

Answer 1

Uses the standardized NIC classification system of care interventions

Question 2

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

A) Provide a means for outcome evaluation
B) Account for the reasoning that drives the nursing action
C) Support the patient's success in achieving the expected outcome
D) Provide information to aide in the implementation of the nursing action

Answer 2

Account for the reasoning that drives the nursing action

Question 3

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

A) "I know my doctors and nurses really care about me."
B) "My medication has really helped lessen my symptoms."
C) "I have hopes that I will be able to lead a productive, healthy life."
D) "My care team has really helped me manage most of my problems."

Answer 3

"My care team has really helped me manage most of my problems."

Question 4

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

A) Clearly stating that the patient must socially interact once daily
B) Documenting that the patient continues to resist socialization
C) Asking the patient to identify which unit activity they are willing to attend
D) Suggesting that staff take the patient with them when running errands off the unit

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?

A) "That's wise, because intuition went out of favor with the scientific revolution."
B) "Critical thinking and intuition are at opposite poles. Keep relying on your expertise."
C) "It's possible that intuition about suicidality is generated by transfer of feelings from the patient to the nurse."
D) "It's been determined that intuition is nothing more that extrasensory perception, so some folks have it, and some don't."

Question 6

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

A) Subscribing to and reading a monthly psychiatric research nursing journal
B) Working on a committee to revise current facility policies regarding the use of chemical restraints
C) Registering to attend a psychiatric workshop on newly developed psychotropic medication therapies
D) Asking an experienced staff member to review the interventions being proposed for a newly admitted patient

Question 7

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

A) Developing a therapeutic relations with the patient
B) Applying evidence-based nursing practice to the plan of care
C) Providing appropriate discharge planning to meet the patient's needs
D) Evaluating the effectiveness of interventions through achievement of outcomes

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:

A) Actually they are very similar in that they both are concerned with helping you get better and lead a happier life.
B) Medical diagnoses are focused on why you are depressed whereas nursing diagnoses are concerned about making your life less sad.
C) Nursing diagnoses are more directed at caring for you, unlike medical diagnoses that focus on finding the cause for your problem.
D) The medical diagnosis identifies that you are experiencing depression whereas the nursing diagnosis identifies how the depression is affecting you.

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:

A) "I really don't think my psychiatrist actually helps me."
B) "I can't decide if I should get my own apartment or not."
C) "I can't accept that I will never be able to comfortably make decisions."
D) "I don't think I'm liked well enough to seek election as a committee chairperson."

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:

A) "Can you work on identifying three situations that cause you to abuse alcohol?"
B) "I'll help you to identify three triggers for your drinking during today's session."
C) "I'm pleased you've identified three situations that trigger your abuse of alcohol."
D) "Do you think you will be able to avoid the three triggers that cause you to drink?"

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:

A) The patient's Axis II includes a diagnosis of mental retardation
B) Documentation that the patient has been noncompliant regarding medications
C) The patient's current Global Assessment of Functioning (GAF) Scale rating is 9
D) Reference to a recent physical injury resulting from the patient's impulsive behavior

Question 12

When engaging in outcomes identification,the nurse:

A) Interviews and collects patient-focused data
B) Re-assesses the patient's physical and emotional status evaluation
C) Reviews the patient's existing problems and projects the results of the nursing care
D) Considers the patient's presenting symptoms and identifies nursing-related problems

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:

A) "Do you think you have a better method we might use?"
B) "The nursing process is a systematic problem-solving method encompassing all components necessary to care for patients."
C) "Using the nursing process is a way of legitimizing our profession and placing us on an equal footing with the pure sciences."
D) "The nursing process is a unidimensional, static, linear approach used to guide nurses as they make clinical judgments."

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:

A) NANDA nursing diagnoses
B) Short-term stress management therapy
C) A specialized clinical pathway for such patients
D) Generic instead of brand name medications

Question 15

The nurse assesses a patient's judgment by asking:

A) "Why did you run away?"
B) "When did you first start hearing voices?"
C) "What would you do if you smelled smoke in your home?"
D) "Do you believe you hear voices, or do you think it is in your mind?"

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:

A) Patient outcomes were partially attained. Implementation of present plan to continue.
B) Patient will initiate and support conversation with nurse therapist by (date 3 weeks in future).
C) Oral medication for anxiety should be administered when depression is assessed to be at the moderate level.
D) Impaired verbal communication r/t impoverished thoughts secondary to depression as evidenced by monosyllabic responses.

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:

A) Reviewing the ED chart
B) Contacting the admitting physician
C) Directing the questions to the family members
D) Establishing a line of communication with the patient

Question 18

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

A) Implements suicide precautions for this patient
B) Includes 'Risk for Self Harm' to the patient's care plan
C) Documents regarding the patient's safety every 15 minutes
D) Reviews the patient's chart for references to past incidences of hopeless

Question 19

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

A) "You always document in ink and never erase or use "white out" in the nursing notes."
B) "It's a document that shows proof that the patient received care that met the expected standards."
C) "Patient charts are carefully protected from unlawful access by inappropriate individuals or institutions."
D) "The patient has a legal right to the information contained in the chart but not the original documentation itself."

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:

A) Hopelessness
B) Powerlessness
C) Ineffective coping
D) Chronic low self-esteem

Question 21

The expert nurse is confident that the novice nurse understands the principles that guide the planning of patient care interventions when the:

A) Novice nurse asks the patient to identify their primary concerns
B) Patient successfully achieves the agreed upon nursing outcomes
C) Expert nurse requests that the novice nurse observe several care planning sessions
D) Novice nurse includes interventions that are supported by evidence-based practices

Question 22

Care planning for a patient diagnosed with paranoid schizophrenia will include:

A) Analyzing effectiveness of care provided
B) Determining the patient's needs and problems
C) Establishing realistic patient-focused outcome criteria
D) Identifying priorities of care based on the patient's condition

Question 23

A well-stated outcome criteria for a patient with a nursing diagnosis of risk for loneliness related to social isolation would include "The patient will:

A) No longer experience loneliness by the end of the fifth day of hospitalization."
B) Agree to attend two on-unit, staff-directed group sessions daily."
C) Continue to maintain social solitude 50% of the time."
D) Interact with a peer on a daily basis by discharge."