Chapter 7: The Nursing Process and Standards of Care

Advanced Practice Registered Nurse Interventions:

Consultation Prescriptive authority and treatment Psychotherapy

Evaluation of the individual's response to treatment should be...

systematic ongoing based on criteria

In patient-centered care, who or what is the nurse's primary source of data?

the patient

What is a hallmark of psychiatric disorders in children?

the tendency to regress

What is the purpose of HIPAA privacy rule?

to ensure that an individual's health information is protected while at the same time allowing healthcare providers to obtain health information for the purpose of giving and promoting high-quality healthcare

The purpose of the psychiatric-mental health nursing assessment is to...

- Establish rapport - Obtain an understanding of the current problem or chief complaint - Review the patient's physical status and obtain baseline vital signs - Assess for risk factors affecting the safety of the patient or others - Perform a mental status examination - Assess psychosocial status - Identify mutual goals for treatment - Formulate a plan of care - Document data in a retrievable format

The nurse considers the following specific principles when interventions are being planned:

- Safe: Interventions must be safe for the patient as well as for other patients, staff, and family - Compatible and appropriate: Interventions must be compatible with other therapies and with the patient's personal goals and cultural values and also institutional rules - Realistic and individualized: Interventions should be (1) within the patient's capabilities given the patient's age, physical strength, condition, and willingness to change; (2) based on the number of staff available; (3) reflective of the actual available community resources; and (4) within the student's or nurse's capabilities - Evidence based: Interventions should be based on scientific evidence and principles when available

Assessment of Children

- caregivers (parents or guardians) can often best describe the child's behavior, performance, and conduct - One of the hallmarks of psychiatric disorders in children is the tendency to regress (i.e., return to a previous level of development). - Watching children at play provides important clues to their functioning. - Play is a safe area for children to act out thoughts and emotions. - Asking the child to tell a story, draw a picture, or engage in specific therapeutic games can be useful, particularly when the child is having difficulty with verbal expression.

Assessment of Adolescents

- concerned with confidentiality and may fear that you will repeat what they say to their parents. - Adolescents should receive an explanation of the role of the treatment team in providing care and the need to share certain information - Threats of suicide, homicide, sexual abuse, or behaviors that put the patient or others at risk for harm are shared with other professionals as well as with the parents - helpful to use a brief structured interview technique such as the HEADSSS interview

Assessment of Older Adults

- five senses (taste, touch, sight, hearing, and smell) and brain function begin to diminish - nurse evaluates physical limitations, which may be sensory (difficulty seeing or hearing), motor (difficulty walking or maintaining balance), or medical (back pain, cardiac or pulmonary deficits) - identify physical deficits at the onset of the assessment and make accommodations - a voice that is lower in pitch is easier for older adults to hear

Language Barriers

- often requires an interpreter or translator to understand the patient's history and healthcare needs - untrained interpreters such as family members, friends, and neighbors may be tempting but do not use them - the cost of even one malpractice lawsuit brought on by incorrect interpretations can be devastating to organizations, not to mention the consequences to the patient

Nursing diagnostic statements are made up of the following structural components:

1. Problem/potential problem - describes the state of the patient at present 2. Probable cause - usually indicate what needs to be addressed to bring about change through nursing interventions 3. Supporting data - signs (objective and measurable) and symptoms (subjective and reported by the patient).

What are the steps in the nursing process?

Assessment Diagnosis Outcomes identification Planning Implementation Evaluation

The HEADSSS Psychosocial Interview Technique

H - Home environment (e.g., relations with parents and siblings) E - Education and employment (e.g., school performance) A - Activities (e.g., sports participation, after-school activities, peer relations) D - Drug, alcohol, or tobacco use S - Sexuality (e.g., whether the patient is sexually active, practices safe sex, or uses contraception) S - Suicide risk or symptoms of depression or other mental disorder S - Safety (e.g., how safe does the patient feel at home and school, wear a safety belt, or engage in dangerous or risky activities)

Milieu management includes the following:

Orienting patients to their rights and responsibilities Providing culturally sensitive care Selecting activities (both individual and group) that meet the patient's physical and mental health needs Using the least restrictive environment

Quality and Safety Education in Nursing Competencies

Patient-centered care Quality Improvement Safety Informatics Teamwork and Collaboration Evidenced-based practice

Standards of Practice for Psychiatric-Mental Health Nursing: Diagnosis

The psychiatric-mental health registered nurse analyzes the assessment data to determine diagnoses, problems, and areas of focus for care and treatment, including level of risk

Standards of Practice for Psychiatric-Mental Health Nursing: Planning

The psychiatric-mental health registered nurse develops a plan that prescribes strategies and alternatives to help the healthcare consumer reach his or her expected outcomes

Standards of Practice for Psychiatric-Mental Health Nursing: Evaluation

The psychiatric-mental health registered nurse evaluates progress toward the attainment of expected outcomes

Standards of Practice for Psychiatric-Mental Health Nursing: Outcomes Identification

The psychiatric-mental health registered nurse identifies expected outcomes and the healthcare consumer's goals for a plan individualized to the healthcare consumer or to the situation

Standards of Practice for Psychiatric-Mental Health Nursing: Implementation

The psychiatric-mental health registered nurse implements the identified plan

Which nursing interventions best demonstrate an understanding of the Quality and Safety Education in Nursing (QSEN) competences? Select all that apply. a. Asking the patient what she expects from the treatment she is receiving b. Seeking recertification for cardiopulmonary resuscitation (CPR) c. Accessing the internet to monitor social media related to opinions on healthcare d. Consulting with a dietitian to discuss a patient's cultural food preferences and restrictions e. Reviewing the literature regarding the best way to monitor the patient for a fluid imbalance

a. Asking the patient what she expects from the treatment she is receiving b. Seeking recertification for cardiopulmonary resuscitation (CPR) d. Consulting with a dietitian to discuss a patient's cultural food preferences and restrictions e. Reviewing the literature regarding the best way to monitor the patient for a fluid imbalance

A nurse is about to interview an older client whose glasses and hearing aid were placed in the bedside drawer for safe keeping. Before beginning the interview, which nursing intervention that will best facilitate data collection? a. Assist the client in putting on glasses and hearing aid. b. Give the client her glasses and hearing aid. c .Ask the client if she needs her glasses and hearing aid. d. Explain the importance of wearing her hearing aid and glasses.

a. Assist the client in putting on glasses and hearing aid. A client whose hearing or sight is impaired may have difficulty providing information if these items have been removed from his or her possession. Assisting the client in wearing these assistive devices is the best initial intervention. None of the other options will be as effective in facilitating the interview.

Amadi is a 40-year-old African national being treated in a psychiatric outpatient setting due to a court order. Amadi's medical record is limited in scope, so where can Renata, his registered nurse, obtain more data on Amadi's condition within legal parameters? Select all that apply. a. Emergency department records b. Police records related to the offense resulting in the court order for treatment c. Calling his family in Africa for details about Amadi's mental health d. Past medical records in the current facility

a. Emergency department records b. Police records related to the offense resulting in the court order for treatment d. Past medical records in the current facility

What is the purpose of the Health Insurance Portability and Accountability Act (HIPAA)? Select all that apply. a. Ensuring that an individual's health information is protected b. Providing third-party players with access to patient's medical records c. Facilitating the movement of a patient's medical information to the interested parties d. Guaranteeing that all those in need of healthcare coverage have options to obtain it e. Allowing healthcare providers to obtain health information to provide high-quality healthcare.

a. Ensuring that an individual's health information is protected e. Allowing healthcare providers to obtain health information to provide high-quality healthcare.

Which criterion is essential when the nurse plans nursing interventions designed to meet a specific goal? Select all that apply. a. Evidence based b. Safe c. Economical d. Individualized e. Realistic

a. Evidence based b. Safe d. Individualized e. Realistic Although expense should be considered, interventions are chosen based on being safe, compatible and appropriate, realistic and individualized, and evidence based and not on their economic value.

A nurse identified a nursing diagnosis of self-mutilation for a female diagnosed with borderline personality disorder. The patient has multiple self-inflicted cuts on her forearms and inner thighs. What is the most important patient outcome for this nursing diagnosis? Patient will a. Identify triggers to self-mutilation b. Refrain from self-harm c. Describe strategies to increase socialization on the unit d. Describe two strategies to increase self-care

a. Identify triggers to self-mutilation

During an interview with a non-English-speaking middle-aged woman recently diagnosed with major depressive disorder, the patient's husband states, "She is happy now and doing very well." The patient, however, sits motionless, looking at the floor, and wringing her hands. A professional interpreter would provide better information due to the fact that a family member in the interpreter role may: Select all that apply. a. Be too close to accurately capture the meaning of the patient's mood b. Censor the patient's thoughts or words c. Avoid interpretation d. Leave out unsavory details

b. Censor the patient's thoughts or words

psychiatric disorders can lead to physical or somatic symptoms such as...

abdominal discomfort headaches lethargy insomnia intense fatigue pain

Subjective data refers to

all information that you gather from a patient and from people who may accompany the patient

Objective data refers to

all things that nurses observe or are verified through tests. Examples: heart rate, blood pressure, body temperature, oxygen saturation, height, weight, and levels of consciousness based on a rating scale.

The nursing process is intended to facilitate and identify...

appropriate, safe, culturally competent, developmentally relevant quality care for individuals, families, groups, or communities

Consultation involves...

assisting other registered nurses and members of the interprofessional team in addressing complex clinical and other situations.

The nurse is conducting an admission interview with a client who was raped 2 weeks ago. When asked about the rape, the client becomes very anxious and upset and begins to sob. What should be the nurse's response to the client's reaction? a. Reassure the client that anything she says to you will remain confidential. b. Acknowledge that the topic of the rape is upsetting and reassure the client that it can be discussed at another time when she feels more comfortable. c. Use silence as a therapeutic tool and wait until the client is done sobbing to continue discussing the rape. d. Push gently for more information about the rape because the information needs to be documented.

b. Acknowledge that the topic of the rape is upsetting and reassure the client that it can be discussed at another time when she feels more comfortable. The best atmosphere for conducting an assessment is one with minimal anxiety on the client's part. If a topic causes distress, it is best to abandon the topic at that time. It is important not to pry or push for information that is difficult for the client to discuss. The use of silence continues to expect the client to discuss the topic now. Reassurance of confidentiality continues to expect the client to discuss the topic now.

The client's priority nursing diagnosis has been established as risk for self-directed violence: suicide related to multiple losses. What is the priority outcome for this client? a. Attend self-help group daily. b. Refrain from attempting suicide. c. State absence of feelings of powerlessness. d. Be placed on suicide precautions.

b. Refrain from attempting suicide. Refraining from suicidal attempts is the only outcome that addresses the risk for self-directed violence. The absence of a feeling of powerlessness is not appropriate for the stated nursing diagnosis. The remaining options are interventions.

Medical records are considered legal documents. Proper documentation needs to reflect patient condition along with changes. It should also be based on professional standards designated by the state board of nursing, regulatory agencies, and reimbursement requirements. Proper documentation can be enhanced by: a. Only using objective data b. Using the nursing process as a guide c. Using language the specific patient can understand d. Avoiding legal jargon

b. Using the nursing process as a guide

Which response should the nurse provide a client who asks, "Why you need to conduct an assessment interview"? a. "The assessment interview lets you have an opportunity to express your feelings." b. "You are able to tell me in detail about your past so that we can determine why you are experiencing mental health alterations." c. "We will be able to form a relationship together where we can discuss the current problems and come up with goals and a plan for treatment." d. "I need to find out more about you and the way you think in order to best help you."

c. "We will be able to form a relationship together where we can discuss the current problems and come up with goals and a plan for treatment." Some of the purposes of the assessment interview are to establish rapport, learn more about the presenting issues, and form mutual goals and a plan for treatment. The other options do not appropriately explain the assessment purpose.

A 26-year-old client is brought to the emergency room by a friend. The client is unable to give any coherent history. Which response should the nurse provide when the client's friend offers to provide information regarding the client? a. "Yes, however, we will have to get a release signed from the client for you to be able to talk with me." b. "There is no need for that as I will call his primary care provider to obtain the information we need." c. "Yes, I will be happy to get any information and history that you can provide." d. "I'm sorry, but I cannot take any information from you as it would violate confidentiality laws."

c. "Yes, I will be happy to get any information and history that you can provide." The friend is a secondary source of information that will be helpful since the client is not able to give any history or information at this time. Confidentiality laws do not prohibit obtaining information from a secondary source. The friend can provide information and/or history immediately and may be able to relate events that happened just before coming to the hospital. A release would not be necessary to take information about the client from a secondary source, and a psychotic client would not be competent to sign a release.

Which intervention demonstrates a nurse's understanding of the initial action associated with the assessment of a patient's spiritual beliefs? a. Offering to pray with the patient b. Providing a consult with the facility's chaplain c. Asking the patient what role spirituality plays in his daily life d. Arranging for care to be provided with respect to religious practices

c. Asking the patient what role spirituality plays in his daily life

Which disadvantage is inherent to the problem-oriented charting system (SOAPIE)? a. Does not support a universal organizational system b. Commonly allows for the inclusion of subjective information c. Documentation is not listed in chronological order d. Does not support the nursing process as a format

c. Documentation is not listed in chronological order

What principle forms the basis of nursing outcome planning? a. The goal of nursing action is to create a dependency between the client and the caregiver. b. Nursing interventions are designed to solve individuals' problems for them. c. Individuals have the right to outcomes that is reflective of their abilities. d. Nurses have the best understanding of client problems and so they direct outcome selection.

c. Individuals have the right to outcomes that is reflective of their abilities. Outcome criteria are the hoped-for outcomes that reflect the maximal level of patient health that the patient can realistically achieve through nursing interventions. None of the other options accurately describes the guiding principle of outcome planning.

Which tool can the novice nurse might refer to when writing nursing outcomes? a. Nursing Interventions Classification (NIC) b. Joint Commission (formally JCAHO) c. International Classification for Nursing Practice (ICNP) d. North American Nursing Diagnosis Association (NANDA)

c. International Classification for Nursing Practice (ICNP) International Classification for Nursing Practice ([ICNP], 2017) provides a classification of nursing diagnoses. In addition to these diagnoses, the INCP also provides nursing interventions, and nursing outcomes. That is not the function of any of the other options.

What three structural components comprise a nursing diagnosis? a. Unmet need, goal, outcome criterion b. Problem, outcome, intervention c. Problem, probable cause, supporting data d. Presenting symptom, treatment, goal

c. Problem, probable cause, supporting data Nursing diagnostic statements are made up of the following structural components: problem/potential problem, probable cause, and supporting data.

A nursing diagnosis is a...

clinical judgment about a patient's response to actual and potential problems

Evidence-based practice (EBP) for nurses is a...

combination of clinical skill and the use of clinically relevant research in the delivery of effective patient-centered care

Evaluation of care is a...

continual process of determining to what extent the outcome criteria have been achieved. The plan of care may be revised based on the evaluation.

Psychiatric-mental health nursing practice includes five basic-level interventions:

coordination of care health teaching and health promotion milieu therapy pharmacological, biological, and integrative therapies therapeutic relationships and counseling

A 17-year-old client confides to the nurse that they have been thinking of ways to kill a peer. What response should the nurse give when the client states, "you have to keep it a secret because its confidential information"? a. "I will have to share this with the treatment team, but we will not share it with your parents." b. "Yes, I will keep it confidential. We have laws to protect clients' confidentiality." c. "I will keep it a secret, but you and I need to discuss ways to deal with this situation appropriately without committing a crime." d. "Issues of this kind have to be shared with the treatment team and your parents."

d. "Issues of this kind have to be shared with the treatment team and your parents." Although adolescent clients request confidentiality, issues of sexual abuse, threats of suicide or homicide, or issues that put the client at risk for harm must be shared with the treatment team and the parents. A threat of this nature must be discussed with the treatment team and the parents. Confidentiality laws do not protect information that would lead to harm to the client or others.

A 13-year-old boy is undergoing a mental health assessment. The nurse practitioner assures him that his medical records are protected and private. The nurse recognizes that this promise cannot be kept when the youth divulges: a. "I lost my virginity last year." b. "I am angry with my parents most of the time." c. "I have thoughts of being in love with boys." d. "My parents do not know that I hit my grandpa."

d. "My parents do not know that I hit my grandpa."

The nurse best assesses the client's spiritual life by asking which question? a. "Do you practice a specific religion?" b. "To whom do you turn in times of crisis?" c. "Do you attend church regularly?" d. "What role does religion play in your life?"

d. "What role does religion play in your life?" Asking the client to define the role of religion in their life allows for discussion related to the other topics.

Which standardized rating scale will the nurse specifically include in the assessment of a newly admitted patient diagnosed with major depressive disorder? a. Mini-Mental State Examination (MMSE) b. Body Attitude Test c. Global Assessment of Functioning Scale (GAF) d. Beck Inventory

d. Beck Inventory

Which nursing diagnosis for a psychiatric client is correctly structured and worded? a. Hopelessness related to severe chronic depression b. Spiritual distress as evidenced by client stating "God has abandoned me because I'm a bad person" c. Defensive coping related to lack of insight associated with illicit drug use d. Imbalanced nutrition: less than body requirements related to poor self-concept as evidenced by reporting "I'm not worthy of eating"

d. Imbalanced nutrition: less than body requirements related to poor self-concept as evidenced by reporting "I'm not worthy of eating" This diagnosis contains all the required components: problem statement, related factors, and defining characteristics.

The mental status examination aids in the collection of what type of data? a. Covert b. Physical c. Subjective d. Objective

d. Objective The mental status exam mostly aids in the collection of objective data.

A 43-year-old client being seen in the mental health clinic states, "I have always been a practicing Jew, but in the past few months I am questioning everything. I just don't know if I believe in it anymore." Which of the following nursing diagnoses best describes the client's comment? a. Ineffective coping b. Risk for self-harm c. Hopelessness d. Spiritual distress

d. Spiritual distress The client is expressing distress regarding his religion and spiritual well-being. The client could be experiencing ineffective coping, but this does not directly relate to his comment. There is nothing in the client's comment that would lead to the conclusion that the client is having thoughts of harming himself or experiencing hopelessness.

What is the primary source for data collection during a psychiatric nursing assessment? a. client's nonverbal responses. b. client's medical treatment records. c. client's family and friends. d. client's own words and actions.

d. client's own words and actions. The client should always be considered the primary data source. At times, however, the client will be unable to fulfill this role.

the nurse implements the plan using...

evidence-based interventions whenever possible, utilizing community resources collaborating with colleagues

religion is an...

external system that includes beliefs, patterns of worship, and symbols

Outcome criteria

hoped-for outcomes that reflect the maximum level of patient health that the patient can realistically achieve through nursing interventions.

Spirituality refers to...

how we find meaning, hope, purpose, and a sense of peace in our lives

Hyperthyroidism may share symptoms (e.g., anxiety, weight loss, insomnia) with a...

hypomanic or manic phase of bipolar disorder

A vital part of health promotion is...

identifying resources for services in the community

Hypothyroidism may have the clinical appearance of...

major depressive disorder

What secondary sources are used in data collection for a patient?

members of the family friends neighbors police healthcare workers medical records

Milieu therapy is a...

psychiatric philosophy that involves a secure environment including people, settings, structure, and emotional climate to support recovery.M takes naturally occurring events in the environment and uses them as learning opportunities for patients.

Standards of Practice for Psychiatric-Mental Health Nursing: Assessment

psychiatric-mental health registered nurse collects and synthesizes comprehensive health data pertinent to the healthcare consumer's health and/or situation

Ongoing assessment of data allows for...

revisions of nursing diagnoses changes to more realistic outcomes or identification of more appropriate interventions when outcomes are not met.