Question 1

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

Accepted Answer

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

Question 2

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

Accepted Answer

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. D

Question 3

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.)

Accepted Answer

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." B, C, E

Question 4

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

Accepted Answer

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 5

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"?

Accepted Answer

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

Question 6

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

Accepted Answer

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 7

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?

Accepted Answer

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 8

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.

Accepted Answer

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

Question 9

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?

Accepted Answer

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 10

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.

Accepted Answer

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

Question 11

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

Accepted Answer

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

Question 12

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

Accepted Answer

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 13

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

Accepted Answer

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 14

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.

Accepted Answer

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.

Question 15

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?

Accepted Answer

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 16

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

Accepted Answer

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 17

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

Accepted Answer

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 18

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?

Accepted Answer

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

Question 19

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.)

Accepted Answer

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

Question 20

"QSEN" refers to

Accepted Answer

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

Exam 7: The Nursing Process and Standards of Care