Ch 9 Nursing Process QUESTIONS Townsend

20. A client is recovering from abdominal surgery. In order to maximize the learning process prior to discharge teaching, which assessment should be performed by the nurse?

A. Assessing the client's level of pain ANS: A Pain will distract the client and interfere with the learning process.

17. A student nurse asks an instructor how best to develop nursing outcomes for clients. Which reply by the instructor most accurately answers the student's question?

C. "Use the Nursing Outcomes Classification (NOC) as a reference for nursing outcomes." ANS: C NOC is a comprehensive, standardized classification of client outcomes developed to evaluate the effects of nursing interventions.

32. Which of the following characteristics of accurately developed client outcomes should a nurse identify? (Select all that apply.)

C. Client outcomes are specific and measurable. D. Client outcomes are realistically based on client capability. ANS: C, D (The nurse should identify that client outcomes should be specific, measurable, and realistically based on client capability. Outcomes should be derived from the diagnosis and should include a time estimate for attainment. Outcomes are most effective when formulated cooperatively by the interdisciplinary team members, client, and significant others.)

12. A nurse on an inpatient psychiatric unit implements care by scheduling client activities, interacting with clients, and maintaining a safe therapeutic environment. These actions reflect which role of the nurse?

C. Milieu manager ANS: C The milieu manager implements care by scheduling client activities, interacting with clients, and maintaining a safe therapeutic environment. (Health teaching involves promoting health and a safe environment. Case management is utilized to organize client care so that outcomes are achieved. Psychotherapy involves conducting individual, couples, group, and family counseling.)

24. Which nursing response would be appropriately used in the evaluation phase of the nursing process?

D. "This new approach seems to work for you." ANS: D In the evaluation phase of the nursing process, the nurse evaluates progress toward attainment of the expected outcomes.

23. An instructor overhears a student say, "That family seems to disagree more than agree. The family seems to be dysfunctional." To further assess the family's situation, which would be an appropriate instructor reply?

D. "What appears to trigger family disagreements?" ANS: D (In the assessment phase of the nursing process, the nurse collects comprehensive health data that are pertinent to the client's health or situation.)In this situation, prior to intervening with this family, the nurse needs further information about the cause of family conflicts.

27. An adolescent client has problems expressing anger appropriately. Which nursing statement would encourage the client to set realistic goals?

A. "What do you think needs to change about how you express anger?" ANS: A In the planning phase of the nursing process, the nurse works with the client to identify expected outcomes for a plan individualized to the client or to the situation.

13. The following outcome was developed for a client: "Client will list five personal strengths by the end of day 1." Which correctly written nursing diagnostic statement most likely generated the development of this outcome?

A. Altered self-esteem R/T years of emotional abuse AEB self-deprecating statements ANS: A The nurse should determine that altered self-esteem and self-deprecating statements would generate the outcome to list personal strengths by the end of day 1. Self-care deficit, disturbed body image, and risk for disturbed self-concept would generate specific outcomes in accordance with specific needs and goals. The self-care deficit and risk for disturbed self-concept nursing diagnoses are incorrectly written.

31. Which of the following nursing interventions fall within the standards of psychiatric-mental health clinical nursing practice for a nurse generalist? (Select all that apply.)

A. Assist clients to perform activities of daily living. C. Encourage clients to discuss triggers for relapse. E. Educate families about signs and symptoms of alcohol dependence and withdrawal. ANS: A, C, E (Assisting clients to perform daily living activities, encouraging clients to discuss triggers, and educating families are nursing interventions that fall within the standards of psychiatric clinical nursing practice for a nurse generalist. Psychiatric-mental health advanced practice registered nurses can consult with other clinicians and use prescriptive authority.)

8. The nurse should recognize which acronym as representing problem-oriented charting?

A. SOAPIE ANS: A The acronym SOAPIE represents problem-oriented charting which reflects the subjective, objective, assessment, plan, implementation, and evaluation format. This type of charting identifies nursing diagnoses (client problems) on a written plan of care with appropriate nursing interventions described for each.

16. The following North American Nursing Diagnosis Association (NANDA) nursing diagnostic stem was developed for a client on an inpatient unit: Risk for injury. What assessment data most likely led to the development of this problem statement?

A. The client is receiving electroconvulsive therapy (ECT) and is diagnosed with Parkinsonism. ANS: A The nurse should identify that a client receiving ECT and who is diagnosed with Parkinsonism is at risk for injury due to confusion and potential for falls. History of suicide and hopelessness would lead to the development of a risk for suicide nursing diagnosis. Disorganized thoughts and delusional thinking would lead to the development of an altered thought process nursing diagnosis.

4. Which expected client outcome should a nurse identify as being correctly formulated? D. Client will initiate interaction with one peer during free time within 2 days.

ANS: D (The statement "Client will initiate interaction with one peer during free time within 2 days." is an example of a correctly formulated expected outcome. Outcomes should be measurable, realistic, client-focused goals that include a time frame. Appropriate nursing interventions are guided by client outcomes)

19. A nurse is evaluating the effectiveness of teaching after instructing a group of clients on joint replacement. In the evaluation step of the nursing process, which learning domain is the most difficult to measure?

B. Affective domain ANS: B Affective knowledge is the most difficult to evaluate because of differences in values, cultures, and attitudes.

18. A client diagnosed with schizophrenia is exhibiting nonverbal behaviors indicating that the client is hearing things that others do not. Which nursing diagnosis accurately reflects this client's problem?

B. Altered sensory perception ANS: B The nursing diagnosis altered sensory perception accurately reflects the client's symptoms of hearing things that others do not. (A nursing diagnosis describes a client's condition and facilitates the prescription of interventions. Delusional thinking, confusion, and disorientation are problems associated with the nursing diagnosis of altered thought processes.)

2. Which statement is most accurate regarding the assessment of clients diagnosed with psychiatric problems?

B. Assessment provides a holistic view of the client including biopsychosocial aspects ANS: B The assessment of clients diagnosed with psychiatric problems should provide a holistic view of the client. (A thorough assessment involves collecting and analyzing data from the client, significant others, and health-care providers that may include the following dimensions: physical, psychological, sociocultural, spiritual, cognitive, developmental, economic, lifestyle, and functional abilities)

14. How should a nurse prioritize nursing diagnoses?

B. By the life-threatening potential ANS: B The nurse should prioritize nursing diagnoses related to life-threatening potential. Safety is always the nurse's first priority.

11. What is the purpose when a nurse gathers client information?

B. It enables the nurse to make sound clinical judgments and plan appropriate client care. ANS: B The purpose of gathering client information is to enable the nurse to make sound clinical judgments and plan appropriate care. The nurse should complete a thorough assessment of the client including information collected from the client, significant others, and health-care providers.

3. Which nursing diagnosis should a nurse identify as being correctly formulated?

B. Self-care deficit: hygiene R/T altered thought as AEB disheveled appearance ANS: B (The nurse should determine that the correctly written diagnosis would be Self-care deficit: hygiene R/T altered thought AEB disheveled appearance. The nursing diagnosis should describe the client's condition, facilitating the choice of interventions)

21. During the implementation phase of the nursing process, a nurse is teaching an adult with a cochlear implant about medications. Which modification in the teaching plan would be the most appropriate for this client?

B. Speaking directly face-to-face ANS: B Speaking face-to-face is an appropriate way to teach individuals with alterations in hearing.

29. A client is assigned the nursing diagnosis of impaired social interaction R/T socio-cultural differences AEB client stating, "Although I'd like to, I don't join in because I don't speak the language so good." Which correctly written outcome addresses this client's problem?

B. The client will participate in one group activity of choice by day 2 ANS: B In the planning phase of the nursing process, the nurse works with the client to identify expected outcomes for a plan individualized to the client need or to the situation.

33. After a comprehensive assessment, correctly written nursing diagnoses developed for psychiatric clients may include which of the following components? (Select all that apply.)

B. Unmet client needs present at the moment C. Supporting data that validate the diagnosis E. Statements of client problems of a functional nature ANS: B, C, E (A nursing diagnosis is a statement of a client's functional problem. An actual nursing diagnosis must include related to (R/T) and as evidenced by (AEB) statements. A risk for diagnosis does not contain AEB because there is only a potential for the problem, it does not as yet exist)

6. Within the nurse's scope of practice, which function is exclusive to the advance practice psychiatric nurse?

B. Using psychotherapy to improve mental health status ANS: B The advanced practice psychiatric nurse is authorized to use psychotherapy to improve mental health. (This includes individual, couples, group, and family psychotherapy. It is within the scope of practice of a registered psychiatric mental health nurse generalist to provide education, case management, and milieu therapy)

28. The nurse interviewed a client who was uncooperative, answered questions with minimal responses, and rarely made eye contact. Which is the most complete documentation of baseline data obtained during the interview?

C. "States, 'I don't need to be here.' when discussing admission status. Maintains minimal eye contact and offers little data related to triggers for admission." ANS: C (Documentation occurs in the implementation phase of the nursing process.) All charting entries to the client's legal record should be objective and based on assessed data. (Implications and generalizations should be avoided.)

25. A client diagnosed with major depressive disorder states, "Why should I keep trying to get a job? I mess up everything I do." Which correctly written nursing diagnosis best reflects the content and mood themes in this client's statement?

C. Altered role performance R/T the fear of failure AEB not seeking employment ANS: C (An actual nursing diagnosis must include related to (R/T) and as evidenced by (AEB) statements. A risk for diagnosis does not contain AEB because there is only a potential for the problem, it doesn't as of yet exist.)The client's statement indicates that role performance is altered due to the fact that fear of failure prevents seeking employment.

1. Which data gathering technique is employed during the assessment phase of the nursing process?

C. Asking the client to describe any thoughts of self-harm ANS: C The nurse should ask the client to describe any thoughts of self-harm during the assessment phase of the nursing process. (Assessment involves collecting and analyzing data about the client that may include the following dimensions: physical, psychological, sociocultural, spiritual, cognitive, developmental, economic, lifestyle, and functional abilities)

9. Which tool would be appropriate for a nurse to use when assessing mental acuity prior to and immediately following electroconvulsive therapy (ECT)?

C. MMSE ANS: C The MMSE, or mini mental status exam, would be the appropriate tool to use to assess the mental acuity of a client prior to and immediately following ECT.

5. Which statement regarding nursing interventions should a nurse identify as accurate?

C. Nursing interventions occur independently but in concert with overall treatment team goals. ANS: C (The nurse should understand that nursing interventions occur independently but in concert with overall treatment goals. Nursing interventions should be developed and implemented in collaboration with other health-care professionals involved in the client's care)

10. What is being assessed when a nurse asks a client to identify name, date, residential address, and situation?

C. Orientation ANS: C The nurse should ask the client to identify name, date, residential address, and situation to assess the client's orientation. Assessment of the client's orientation to reality is part of a mental status evaluation.

30. The following clients are seen in the emergency department. The psychiatric unit has one remaining bed. The triage nurse should expect which client to be admitted?

C. The client who is a single parent and hears voices stating, "Kill your infant son" ANS: C (In the assessment phase of the nursing process, the nurse collects comprehensive health data that are pertinent to the client's health or situation). These data are prioritized to meet client needs with an emphasis on safety.

15. A client has a nursing diagnosis of Insomnia R/T paranoid thinking AEB midnight awakenings, difficulty falling asleep, and daytime napping. Which is a correctly written and appropriate outcome for this client's problem?

C. The client will sleep 7 uninterrupted hours by day four of hospitalization. ANS: C The outcome "The client will sleep 7 uninterrupted hours by day four of hospitalization." is accurately written and an appropriate outcome to address the client problem of insomnia. Outcomes should be measurable, realistic, client-focused goals that include a time frame. Appropriate nursing interventions are guided by client outcomes.

26. During an intake interview, which question would assist the nurse in gathering data about the client's judgment?

D. "If you found a stamped, addressed envelope in the street, what would you do?" ANS: D (In the assessment phase of the nursing process, the nurse collects comprehensive health data that are pertinent to the client's health or situation.) The nurse presents a situation that requires the client to make a judgment call and can assess appropriate judgment based on the client's action choice.

7. A nurse charts "Verbalizes understanding of the side effects of Prozac." This is an example of which category of focused charting?

D. Response ANS: D "Verbalizes understanding of the side effects of Prozac." is an example of the response category of focused charting. The response is a description of the client's reaction to any part of medical or nursing care.

22. A client who has slept 6 hours the previous night reports this to the assigned psychiatric nurse. What should be the initial nursing action to address this situation?

D. Review the client's normal sleep pattern. ANS: D (In the assessment phase of the nursing process, the nurse collects comprehensive health data that are pertinent to the client's health or situation.) In this situation, the nurse must initially determine the client's normal sleep patterns in order to evaluate if a true problem exists.