treatment of mental health disorders, mental health disorders and addictions and physical assessment.

1.Assessment 2.Diagnosis 3.Planning 4.Implementation 5.Evaluation The nursing process is a critical thinking process that the nurse uses to apply the best available evidence to caregiving and promote health functions. The first step of the process is assessment. In this step, the nurse gathers and analyzes information about the client's health status. The second step of the process is diagnosis. The nurse uses assessment findings to make clinical judgments and identify the client's response to health problems in the form of nursing diagnoses. The third step of the process is planning. In this step, the nurse sets goals and expected outcomes for the client's care. The nurse selects interventions (nursing and collaborative) individualized to each of the client's nursing diagnoses. The fourth step of the process is implementation, which involves performing the planned interventions. In the fifth step, the nurse evaluates the client's response and whether the interventions were effective. The nursing process is dynamic and continuous.

The nurse applies the nursing process while caring for clients. Which is the correct order of steps of the nursing process? Diagnosis Evaluation Planning Implementation Assessment

Strong A pulse strength of 3+ is considered full or strong. A bounding pulse is 4+. A pulse strength is considered normal and expected when it is 2+. The pulse strength is diminished or barely palpable when the score is 1+.

The nurse assessed a client's pulse rate and recorded the score as 3+. Which describes the strength of the pulse? Strong Bounding Expected Diminished

Skin turgor is assessed by gently pinching the skin and releasing it while observing the degree of elasticity. If the skin pinch remains elevated or is slow to return to its original position, this may be an indication of dehydration or deficient fluid volume. This assessment technique is not appropriate for assessing pain tolerance, checking for ecchymosis formation, or measuring tissue mass.

The nurse pulls up on the client's skin and releases it to determine whether the skin returns immediately to its original position. Which is the nurse assessing for? Pain tolerance Skin turgor Ecchymosis formation Tissue mass

fecal matter The reservoir for Hepatitis A is fecal matter, so the nurse is particularly careful with any contact with fecal matter to prevent transmission of infection. Gonorrhea is contained in the genitourinary tract. Herpes is contained in saliva. Hepatitis B is contained in the blood.

When assessing a client with Hepatitis A, the nurse is particularly careful with which substance to prevent transmission of the disease? Urine Saliva Blood Fecal matter

Constant singing would be typical in a client with bipolar disorder, manic phase. Ritualistic behavior is indicative of obsessive-compulsive disorder. A flat affect and apathetic demeanor are more indicative of a schizophrenic or depressive disorder.

Which assessment finding would the nurse observe in a client with bipolar disorder, manic phase? Constant singing Ritualistic behavior Flat affect Apathetic demeanor

Reliving the trauma in dreams and flashbacks Experiencing the actual trauma in dreams or flashbacks is the major symptom that distinguishes post-traumatic stress disorders from other anxiety disorders. Lack of interest in family and others is usually not associated with anxiety disorders. Avoidance of situations that resemble the stress is more common with phobic disorders. Blunted affect that occurs during discussion of a traumatic situation is more characteristic of acute stress disorder.

Which characteristic distinguishes post-traumatic stress disorders from other anxiety disorders? Lack of interest in family and others Reliving the trauma in dreams and flashbacks Avoidance of situations that resemble the stress

Underlying pathophysiology Psychophysiological disorders have an underlying pathophysiology or actual physical cause, whereas somatic symptom disorders usually do not. The psychophysiological response (e.g., hyperfunction or hypofunction) produces actual tissue change. Somatic symptom disorders are unrelated to organic changes. There is an emotional component in both instances. There is a feeling of illness in both instances. There may be a restriction of activities in both instances

Which characteristic uniquely associated with psychophysiological disorders would differentiate them from somatic symptom disorders? Emotional cause Feeling of illness Restriction of activities Underlying pathophysiology

It helps the client control the level of anxiety the client is experiencing It helps the client control the level of anxiety the client is experiencing. The rituals help control anxiety by maintaining a set pattern of action. The reason for the ritual is under unconscious control, not conscious control. Rituals are generally seen by the client as illogical; they provide few secondary gains. Rituals are a means of diverting attention from an anxiety-producing situation; it does not focus on the inability to cope with reality.

Which guideline would the nurse use when developing a plan of care for a client with an obsessive-compulsive disorder about ritualistic behavior? It is under conscious control. It is used primarily for secondary gains. It helps the client focus on the inability to cope with reality. It helps the client control the level of anxiety the client is experiencing

Its major clinical manifestation is easy distractibility. A major clinical manifestation is distractibility. The stimuli may come from external sources or internal sources. Selective attention is common, in which the child has difficulty attending to "nonpreferred" tasks, such as completing chores or finishing homework. This problem usually becomes evident before age 12 and is noted in at least two different settings (e.g., school and home). Socioeconomic factors do not play a major role in the occurrence of this disorder. Children with ADHD sleep less than do children without ADHD.

Which information would the school nurse include in an educational program on attention-deficit/hyperactivity disorder (ADHD) to the staff of an elementary school? It becomes evident after age 12 years. Its major clinical manifestation is easy distractibility. It occurs more often in lower socioeconomic groups. It causes affected children to sleep more than unaffected children

Assign the client to a room near the nurses' station for closer supervision at night The nurse would assign the client to a room near the nurse's station for closer supervision at night because the client has nighttime wandering. It is the nurse's responsibility to ensure the safety of clients; close supervision can help ensure that the client does not wander. Restraints should not be used without a primary health care provider's order; a restraint is too excessive an intervention to prevent wandering. The issue is not that the client does not sleep; the issue is that the client wanders, and sedatives can increase confusion in older adult clients. It is the responsibility of the facility (not the family), specifically the nurse, to meet the needs of and ensure the safety of clients.

Which intervention would the nurse include in the nursing home plan of care for an older adult with Alzheimer disease who has nighttime wandering? 1 Order a vest restraint for the client to be applied at night. 2 Obtain a prescription for a sedative so the client will sleep better at night. 3 Request that the family provide a companion to stay with the client at night. 4 Assign the client to a room near the nurses' station for closer supervision at night.

Keeping the child from inflicting any self-injury The nursing objective is to keep the child from inflicting any self-injury. All nursing care would be directed toward preventing injury, particularly with a self-destructive child. Although improved communication skills are important, this is usually not an issue with ADHD. Although formulation of realistic ego boundaries is important, it is not the priority. Opportunities to discharge energy are important, but prevention of injury is the priority.

Which nursing objective would the nurse add to the plan of care for a child with attention-deficit/hyperactivity disorder (ADHD) who engages in self-destructive behavior? Keeping the child from inflicting any self-injury Assisting the child to improve communication skills Helping the child formulate realistic ego boundaries Providing the child with opportunities to discharge energy

"I don't get hard during sex anymore." The statement "I don't get hard during sex anymore" indicates a sexual excitement disorder, which is a partial or complete failure to achieve a physiological or psychological response to sexual activity. The statement "I have no interest in sex" may indicate a sexual dysfunction in which the individual has deficient or absent interest in, or extreme aversion to and avoidance of, sexual activity. "I climax almost before we even get started" and "It takes forever before I finally have an orgasm" are both indicative of an orgasmic disorder, which is a delay in or absence of an orgasm or premature ejaculation.

Which statement by a male client during a yearly physical examination indicates to a nurse that the client may have a sexual excitement disorder? 1 "I have no interest in sex." 2 "I don't get hard during sex anymore." 3 "I climax almost before we even get started." 4 "It takes forever before I finally have an orgasm."