Deck 7: The Nursing Process and Standards of Care

Question 1

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

A) participating in 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.

Answer 1

carrying out interventions and coordinating care.

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 HCL 2.5 mg po 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 2 mg po. I: Haloperidol 2 mg po given 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 2 mg po 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 2 mg po 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 2 mg po. I: Haloperidol 2 mg po given at 0900. E: Returned to lounge at 0930 and quietly watched TV."

Question 3

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

Answer 3

Obtain important information from the family member.

Question 4

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 5

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

Question 6

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." Which response by the nurse is appropriate?

A) "That isn't 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 7

The desired outcome for a patient experiencing insomnia is, "Patient will sleep for a minimum of 5 hours nightly within 7 days." At the end of 7 days, review of 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) Examine interventions for possible revision of the target date.

Question 8

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) Implementation
D) Evaluation

Question 9

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."

Question 10

A new staff nurse completes an 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) Prescribe psychotropic medication.
C) Establish therapeutic relationships.
D) Individualize nursing care plans.

Question 11

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

A) show improved use of language.
B) demonstrate improved social skills.
C) become more independent in decision making.
D) select and participate in one group activity per day.

Question 12

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 13

A patient presents to the emergency department with mixed psychiatric symptoms. The admission nurse suspects the symptoms may be the result of a medical problem. Lab results show elevated BUN (blood urea nitrogen) and creatinine. What is the nurse's next best action?

A) Report the findings to the health care provider.
B) Assess the patient for a history of renal problems.
C) Assess the patient's family history for cardiac problems.
D) Arrange for the patient's hospitalization on the psychiatric unit.

Question 14

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

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

Question 15

A nurse wants to assess an adult patient's recent memory. Which question would best yield the desired information?

A) "Where did you go to elementary school?"
B) "What did you have for breakfast this morning?"
C) "Can you name the current president of the United States?"
D) "A few minutes ago, I told you my name. Can you remember it?"

Question 16

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

Question 17

A patient diagnosed with major depressive disorder has lost 20 pounds in one month, has chronic low self-esteem, and a plan for suicide. The patient has taken antidepressant medication for 1 week. Which nursing intervention has the highest priority?

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

Question 18

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

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

Question 19

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

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

The desired outcome for a patient experiencing insomnia is, "Patient will sleep for a minimum of 5 hours nightly within 7 days." At the end of 7 days, review of sleep data shows the patient sleeps an average of 4 hours nightly and takes a 2-hour afternoon nap. The nurse will document the outcome as

A) consistently demonstrated.
B) often demonstrated.
C) sometimes demonstrated.
D) never demonstrated.

Question 21

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?

A) "How did you get to the United States?"
B) "Would you like for a family member to help you talk with me?"
C) "An interpreter is available. Would you like for me to make a request for these services?"
D) "Are you comfortable conversing in English, or would you prefer to have a translator present?"

Question 22

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) Social isolation
D) Powerlessness

Question 23

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.)

A) The patient was uncooperative
B) The patient's subjective responses
C) Only data obtained from the patient's verbal responses
D) A description of the patient's behavior during the interview
E) Analysis of why the patient was unresponsive during the interview

Question 24

"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 25

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?

A) Uses unapproved abbreviations
B) Contains subjective material
C) Too brief to be of value
D) Excessively wordy
E) Meets standards

Question 26

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 27

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?

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

Question 28

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

A) Designing interventions to include in the plan of care
B) Determining the goals and outcome criteria
C) Implementing the nursing plan of care
D) Completing the spiritual assessment

Question 29

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

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

Question 30

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.)

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)