Ch. 7 Nursing Process and Standard of Care

labile

Changing mood rapidly and often

A nurse taught a client about important precautions associated with a new prescription. Afterward, the client accurately summarized major self-management strategies associated with this drug. Which step of the nursing process applies to the client's summarization? a. Assessment b. Analysis c. Planning/outcomes identification d. Intervention e. Evaluation

e. Evaluation

delusions

false beliefs, often of persecution or grandeur, that may accompany psychotic disorders

Hallucinations

false sensory experiences, such as seeing something in the absence of an external visual stimulus

mood

individual emotional state

what to assess when analyzing behavior?

motor, speech, thoughts, cognition

anhedonia

no joy

three components of diagnosis

problem etiology supporting data

hopelessness change in appetite loss of interest in surroundings insomnia/too much of sleep loss of pleasure poor self-care decreased energy

symptoms of depression

affect

the outward display of emotions observable

cormobidities

the simultaneous presence of two chronic diseases or conditions in a patient

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

a, b, c, and e

psychomotor agitation

Increased motor activity associated with restlessness, including physical actions (e.g., fidgeting, pacing, feet tapping, handwringing).

Which nursing intervention best demonstrates an understanding of the QSEN competencies? a. asking the patient what he or she expects from the treatment he or she is receiving b. seeking recertification for cardiopulmonary resuscitation c. accessing the internet to monitor social media related to opinions on healthcare d. consulting with a dietician to discuss a patient's cultural food preferences and restrictions

a, b, d, and e

psychomotor retardation

Visible generalized slowing of movements and speech.

What is the purpose of 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 personal health records to provide high-quality care

a and e

flat affect

a lack of emotional responsiveness

DSM-5

a widely used system for classifying psychological disorders

Amadi is a 40year old African national being treated in a psychiatric outpatient setting due to court order. Amadi's medical record is limited in scope, so where can his 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, b, and d

A nurse identifies 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? a. Identify triggers to self-mutilation b. Demonstrate a decrease in frequency and intensity pf cutting c. Describe strategies in increase socialization on the unit d. Describe two strategies to increase self-care

a. Identify triggers to self-mutilation

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

a. Individuals have the right to outcomes that is reflective of their abilities.

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. Refrain from attempting suicide. b. Be placed on suicide precautions. c. Attend self-help group daily. d. State absence of feelings of powerlessness.

a. Refrain from attempting suicide

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

a. client's own words and actions.

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. 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. c. Use silence as a therapeutic tool and wait until the client is done sobbing to continue discussing the rape. d. 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.

During an interview with a non-English speaking middle-aged women recently diagnosed with major depression, 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

What three structural components comprise a nursing diagnosis? a. Problem, outcome, intervention b. Problem, related factors, defining characteristics c. Unmet need, goal, outcome criterion d. Presenting symptom, treatment, goal

b. Problem, related factors, defining characteristics

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. Spiritual distress c. Risk for self-harm d. Hopelessness

b. Spiritual distress

Medical records are considered legal documents. Proper documentation needs to reflect patient condition along with changes. It should also by based on professional standards designated by the state board of nursing, regulatory agencies, and reimbursement requirements. Proper documentation can be enhanced by: a. Only use subjective 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

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

c. "Issues of this kind have to be shared with the treatment team and your parents."

A 26-year-old patient is brought to the emergency room by a friend. The patient is unable to give any coherent history. Which response should the nurse provide when the patient's friend offers to provide information regarding the patient? a. "I'm sorry, but I cannot take any information from you as it would violate confidentiality laws." 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. "Yes, however, we will have to get a release signed from the patient for you to be able to talk with me."

c. "Yes, I will be happy to get any information and history that you can provide."

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

c. Assist the client in putting on glasses and hearing aid.

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

c. Objective

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 or her life d. arranging for care to be provided with respect to religious practices

c. asking the patient what role spirituality plays in his or her lif

Which disadvantage is inherent to the problem-oriented charting system? 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

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. "A 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"

Which response should the nurse provide a client who asks, "Why you need to conduct an assessment interview"? a. "I need to find out more about you and the way you think in order to best help you." b. "The assessment interview lets you have an opportunity to express your feelings." c. "You are able to tell me in detail about your past so that we can determine why you are experiencing mental health alterations." d. "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. "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."

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?"

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 b. Body Attitude Test c. Global Assessment of Functioning Scale 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"

In which part of the nursing care plan would the nurse expect to find this statement: Offer snacks and finger foods frequently. a. Assessment b. Diagnosis c. Planning and outcomes identification d. Intervention e. Evaluation

d. Intervention

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

d. Nursing Outcomes Classification (NOC)