MH #1

"A durable power of attorney for health care gives your agent authority to make decisions during any illness if you are incapacitated."

A client asks, "What advantage does a durable power of attorney for health care have over a living will?" The nurse should reply:

Milieu therapy

A client is participating in a therapy group and focuses on viewing all team members as equally important in helping the clients to meet their goals. The nurse is implementing which therapeutic approach?

management of milieu safety.

A nurse inspects an inpatient psychiatric unit and finds that exits are free of obstructions, no one is smoking, and the janitors closet is locked. These observations relate to:

Prohibited a patient from using the bathroom

A nurse performed these actions while caring for patients in an inpatient psychiatric setting. Which action violated patient's rights?

A patient was not allowed to have visitors.

A nurse surveys medical record. Which finding signals a violation of patient's rights?

"Neurotransmitters are natural chemicals that pass messages between brain cells."

A patient asks, "What are neurotransmitters? The doctor said mine are imbalanced." Select the nurse's best response.

Implementation

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"?

Primary prevention

After a category 5 tornado hits a community and destroys many homes and businesses, a community mental health nurse encourages victims to describe their memories and feelings about the event. this action by the nurse best demonstrates...

Determining the goals and outcome criteria

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

streamline the care process and reduce costs

Clinical pathways are used in managed care settings to:

Patterns of communication

Culture includes common beliefs and practices in areas such as religion, economics, diet, health, and:

Ask the patient if he is experiencing abdominal pain.

During an intake interview, the nurse observes the patient grimacing and holding his hand over his stomach. The patient previously denied having any pain. What action should the nurse take next?

1mL

Haloperidol (Haldol) 5 mg IM q8h is ordered for agitation. The nurse had 10mg/2mL. How many mLs will the nurse administer?

All of the above

Homelessness is, in part, being blamed on

present a clear danger to self or others

Inpatient hospitalization for persons with mental illness is generally reserved for patients who:

Christianity

It is important for the nurse to be familiar with the religious practices of clients cared for most often in a particular region because attitudes toward health and illness, death and burial, food, and procreation have a strong impact on a clients beliefs and practices. The nurse knows that the religion practiced most often around the world is

carrying out interventions and coordinating care.

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

A willingness to participate in the planning of the care & treatment plan.

On review of the client's record, the nurse notes that the admission was voluntary. Based on this information, the nurse plans care anticipating which client behavior?

You will administer 4 ml/min

Order: Infuse 1000 ml NS solution over 4 hours. Calculate the IV pump flow rate:

0.5

Order: Lanoxin 125 mcg IV daily. Available: Lanoxin 500 mcg/2mL How many milliliters will the nurse administer?

60

Order: Protonix 40 mg daily per available: Protonix 2 mg per 3 mL. Question: How many milliliters of Protonix should be administered?

"Hello. My name is _______ and I am a nurse. How would you like to be addressed by staff?"

Select the best comment for a nurse to begin an interview with an elderly patient:

Helping a person diagnosed with a serious mental illness learn to manage money.

Select the example of tertiary prevention:

Obtain the patients permission for the exchange of information.

The case manager plans to discuss the treatment plan with a patient's family. Select the case managers first action.

Unsecured scatter rugs

The home care nurse is performing an environmental assessment in the home of an older client. Which observation by the nurse requires intervention?

"It is okay for my wife to wear artificial nails as long as she washes her hands properly."

The nurse discusses and demonstrates proper hand hygiene to an immunocompromised patient and his wife. Which statement indicates a need for additional teaching?

Chest tightness

The nurse is assessing a new patient who complains of his chest feeling tight. The patient displays a temperature of 100F and an oxygen saturation of 89% and exportorates frothy mucus. Which finding is an example of subjective data?

Increased lethargy

The nurse is caring for a patient with general sepsis. Which finding should first alert the nurse to a potential complication that warrants immediate attention?

"Aspiration is a concern with an NG tube feeding."

The nurse is developing a plan of care for a client receiving a nasogastric (NG) tube feeding. When formulating the plan of care, what should the nurse consider?

Increasing restlessness

The nurse is monitoring the status of a postoperative client. The nurse would become most concerned with which sign that could indicate an evolving complication?

"Hand hygiene is one of the most effective ways I can prevent the spread of infection."

The nurse is providing infection control teaching to a group of patients. Which statement demonstrates that the patient understands the nurse's teaching?

"It is important that I take my antibiotic until my symptoms have completely resolved."

The nurse is providing infection control teaching to a patient. Which patient statement warrants additional patient teaching?

Safely securing the safety device straps to the side rails

The nurse obtains a prescription from a health care provider to restrain a client and instructs an unlicensed assistive personnel (UAP) to apply the safety device to the client. Which observation of unsafe application of the safety device would indicate that further instruction is required by the UAP?

identify strategies that fit within the cultural context of the patient.

To provide culturally competent care, the nurse should:

milieu management.

When a new patient is hospitalized, a nurse takes the patient on a tour, explains rules of the unit, and discusses the daily schedule. The nurse is engaged in:

level of awareness

When establishing a client's level of consciousness, the nurse is aware that this is determined by assessing the client's:

Monitor closely for harm to self or others.

When reviewing the admission assessment, the nurse notes that a client was admitted to the mental health unit involuntarily. Based on this type of admission, the nurse should provide which intervention for this client?

Teaching parenting skills

Which activity is appropriate for a nurse engaged exclusively in community-based primary prevention?

reports a consistently sad, discouraged, and hopeless mood.

Which assessment finding most clearly indicates that a patient may be experiencing a mental illness? The patient:

Care is centered on the patient

Which component of treatment of mental illness is specifically recognized by Quality and Safety Education for Nurses (QSEN)?

An individual with bipolar disorder in a manic phase.

Which individual may need involuntary hospitalization?

asking the patient what role spirituality plays in his/her daily life

Which intervention demonstrates a nurse's understanding of the initial action associated with the assessment of a patient's spiritual beliefs?

Identifying the cultural norms each patient

Which intervention demonstrates the nurse's understanding of what guides effective nursing care with a diverse patient population?

Secondary

Which level of prevention activities would a nurse in an emergency department employ most often?

Providing frequent updates to the family of a patient currently in surgery

Which nursing intervention demonstrates the ethical principle of beneficence?

Pinch a skinfold on chest to assess for tenting.

Which technique should the nurse employ to best assess skin turgor?

You will administer 13 gtt/min

You need to administer 100 mls of IV fluid over 2 hours. The drop factor is 15. What is the required rate in gtt/min?