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

Question 1

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) Self-esteem-building activities
B) Anxiety self-control measures
C) Sleep enhancement activities
D) Suicide precautions

Answer 1

Suicide precautions

Question 2

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

A) "A: Pacing and muttering to self. P: Sensory perceptual alteration, related to internal auditory stimulation. I: Given fluphenazine (Prolixin) 2.5 mg at 0900, and went to room to lie down. E: Calmer by 0930. Returned to lounge to watch TV."
B) "S: States, 'I feel like I'm ready to blow up.' O: Pacing hall, mumbling to self. A: Auditory hallucinations. P: Offer haloperidol (Haldol) 2 mg. I: (Haldol) 2 mg at 0900. E: Returned to lounge at 0930 and quietly watched TV."
C) "Agitated behavior. D: Patient muttering to self as though answering an unseen person. A: Given haloperidol (Haldol) 2 mg and went to room to lie down. E: Patient calmer. Returned to lounge to watch TV."
D) "Pacing hall and muttering to self as though answering an unseen person. haloperidol (Haldol) 2 mg administered at 0900 with calming effect in 30 minutes. Stated, 'I'm no longer bothered by the voices.'"

Answer 2

"S: States, 'I feel like I'm ready to blow up.' O: Pacing hall, mumbling to self. A: Auditory hallucinations. P: Offer haloperidol (Haldol) 2 mg. I: (Haldol) 2 mg at 0900. E: Returned to lounge at 0930 and quietly watched TV."

Question 3

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

A) "I can always trust my family."
B) "It seems like I always have bad luck."
C) "You never know who will turn against you."
D) "I hear evil voices that tell me to do bad things."

Answer 3

"I hear evil voices that tell me to do bad things."

Question 4

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) Consistently demonstrated
B) Often demonstrated
C) Sometimes demonstrated
D) Never demonstrated

Question 5

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) childhood growth and development.
B) substance use and abuse.
C) educational background.
D) coping strategies.

Question 6

A patient begins a new program to assist with building social skills. In which part of the plan of care should a nurse record the item "Encourage patient to attend one psychoeducational group daily"?

A) Assessment
B) Analysis
C) Planning
D) Implementation
E) Evaluation

Question 7

A new staff nurse completes orientation to the psychiatric unit. This nurse will expect to ask an advanced practice nurse to perform which action for patients?

A) Perform mental health assessment interviews.
B) Establish therapeutic relationships.
C) Prescribe psychotropic medication.
D) Individualize nursing care plans.

Question 8

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) Document the patient's mental status. Obtain other assessment data from the family member.
B) Record the patient's answers to questions on the nursing assessment form.
C) Ask an advanced practice nurse to perform the assessment interview.
D) Call for a mental health advocate to maintain the patient's rights.

Question 9

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"?

A) Implement suicide precautions.
B) Frequently offer high-calorie snacks and fluids.
C) Assist the patient to identify three personal strengths.
D) Observe patient for therapeutic effects of antidepressant medication.

Question 10

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:

A) document the other worker's assessment of the patient.
B) assess the patient based on data collected from all sources.
C) validate the worker's impression by contacting the patient's significant other.
D) discuss the worker's impression with the patient during the assessment interview.

Question 11

Select the best outcome for a patient with this nursing diagnosis: impaired social interaction, related to sociocultural dissonance as evidenced by stating, "Although I'd like to, I don't join in because I don't speak the language very well." The patient will:

A) demonstrate improved social skills.
B) express a desire to interact with others.
C) become more independent in decision making.
D) select and participate in one group activity per day.

Question 12

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:

A) counseling.
B) health teaching.
C) milieu management.
D) psychobiologic intervention.

Question 13

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) Imbalanced nutrition: Less than body requirements
B) Chronic low self-esteem
C) Risk for suicide
D) Hopelessness

Question 14

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) "That is not true. What you tell us is private and held in strict confidence. Your parents have no right to know."
B) "Yes, your parents may find out what you say, but it is important that they know about your problems."
C) "What you say about feelings is private, but some things, like suicidal thinking, must be reported to the treatment team."
D) "It sounds as though you are not really ready to work on your problems and make changes."

Question 15

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

A) participating in the mutual identification of patient outcomes.
B) gathering accurate and sufficient patient-centered data.
C) comparing patient responses and expected outcomes.
D) carrying out interventions and coordinating care.

Question 16

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

A) Mood
B) Attention
C) Orientation
D) Abstraction

Question 17

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) Remain silent.
B) Educate the patient that the outcome is not realistic.
C) Explore with the patient possible consequences of the outcome.
D) Formulate a more appropriate outcome without the patient's input.

Question 18

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?

A) Continue the current plan without changes.
B) Remove this nursing diagnosis from the plan of care.
C) Write a new nursing diagnosis that better reflects the problem.
D) Revise the outcome target date and interventions.

Question 19

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:

A) "Are you having difficulty hearing when I speak?"
B) "How can I make this assessment interview easier for you?"
C) "I notice you are frowning. Are you feeling annoyed with me?"
D) "You're having trouble focusing on what I'm saying. What is distracting you?"

Question 20

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?

A) Behavior
B) Cognition
C) Affect and mood
D) Perceptual disturbances

Question 21

The acronym QSEN refers to:

A) Qualitative Standardized Excellence in Nursing.
B) Quality and Safety Education for Nurses.
C) Quantitative Effectiveness in Nursing.
D) Quick Standards Essential for Nurses.

Question 22

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

A) Medical judgments about the disorder
B) Goals and outcomes for the plan of care
C) Unmet patient needs currently present
D) Supporting data that validate the diagnoses
E) Probable causes that will be targets for nursing interventions

Question 23

A nurse performing an assessment interview for a patient with a substance abuse disorder decides to use a standardized rating scale. Which scales are appropriate? (Select all that apply.)

A) Addiction Severity Index (ASI)
B) Brief Drug Abuse Screen Test (B-DAST)
C) Abnormal Involuntary Movement Scale (AIMS)
D) Cognitive Capacity Screening Examination (CCSE)
E) Recovery Attitude and Treatment Evaluator (RAATE)

Question 24

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) Tell the patient that medication will help this type of thinking.
B) Ask the patient, "Tell me about the problem as you see it."
C) Seek information about when the problem began.
D) Tell the patient, "Your ideas are not realistic."
E) Reassure the patient, "You are safe here."

Question 25

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.

A) Deficient knowledge
B) Ineffective coping
C) Powerlessness
D) Social isolation

Question 26

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?

A) Defensive coping
B) Decisional conflict
C) Risk for other-directed violence
D) Impaired verbal communication

Question 27

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.)

A) Uncooperative patient
B) Patient's subjective responses
C) Only data obtained from the patient's verbal responses
D) Description of the patient's behavior during the interview
E) Analysis of why the patient is unresponsive during the interview

Question 28

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

A) Design interventions to include in the plan of care.
B) Determine the goals and outcome criteria.
C) Implement the nursing plan of care.
D) Complete the spiritual assessment.