RN Nursing Process Assessment
a nurse is discussing the purpose of mental status assessments with a newly hired nurse. which of the following information should the nurse include?
Mental status assessments assess a client's cognitive and behavioral functioning.
a nurse on a behavioral health unit is caring for a newly admitted patient who asks "what is milieu therapy?" which of the following responses should the nurse make?
Milieu therapy is focused on creating a safe environment for healing through trauma-informed therapeutic relationships."
a nurse is discussing the continuum of care with a client. which of the following information should the nurse include?
The continuum of care includes different clinical settings, such as clinics and hospitals.
a nurse on a behavioral health unit is discussing the tasks of the clinical judgement action model with a group of newly licensed nurses. Which of the following information about analyzing cues should the nurse include?
The nurse should use observations, clinical presentation data, and assessment findings to identify the client's mental health alteration.
a nurse is caring for a client. which of the following actions by the nurse demonstrates the evaluating outcomes step of the clinical judgement action model?
revising the plan of care
a nurse is screening a client for alcohol and tobacco use. which of the following types of prevention is nurse demonstrating?
secondary
a nurse is reviewing the purpose of the DSM-5 with a newly licensed nurse. which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
the DSM-5 is a resource that provides information about the clinical manifestations of specific mental heath disorders
a nurse is caring for a client who is at risk for isolation. which of the following is the best outcome for this client?
the client will attend 3 groups per day by the end of the week
a nurse on an inpatient mental health unit is using the clinical judgement model to guide their care of a client. which of the following tasks should the nurse complete to generate solutions. (select all that apply)
- Determine desired outcomes. - Determine the best solution based on evidence. - Determine what resources are needed, including people, equipment, and medications. -
a nurse is preforming a mental status examination for a newly admitted client. which of the following questions should the nurse include in the examination? (select all the apply)
- How would you describe your mood today?" - "What is the date today?" - Can you please show me how to use this pen?"
a group of nurses is discussing implementation of a plan of care for a client who has a mental illness. which of the following nursing actions should be included when implementing a plan of care? (select all the apply)
- Prioritize establishing a therapeutic relationship. - Focus on client-centered, holistic care rather than the client's diagnosis. - Accurately document implementation of the plan of care.
a nurse is using the clinical judgement action model to guide a clients care. which of the following tasks is designed to facilitate the analysis of cues (select all the apply)?
- recognizing patterns - linking cues - determining what is concerning - determining the need for additional information
a nurse is caring for a client who has a care plan goal of having fewer than five panic attacks per week. the client is struggling to meet this goal. which of the following actions should the nurse take?
work with the client to adjust the goal
a nurse is reviewing community assessments with a group of newly licensed nurses. which of the following statements by a newly licensed nurse indicates an understanding of community assessments (select all the apply)?
"Community assessments are used to assess the needs of a particular community or population." "Community assessments identify conditions and disorders that are prevalent within a community." "Community assessments highlight areas of strength within a community or population." "Community assessments are used to consider the services that are being used in the community."
a nurse is caring for a client who was administered an antianxiety medication 1 hr ago. which of the following statements by the nurse indicates that the nurse is using the evaluation step of the nursing process?
"How is your anxiety level now?"
a group of nurses is discussing the effectiveness of nursing interventions among clients who have a mental health diagnosis. which of the following statements accurately identifies a barrier to effective nursing interventions (select all that apply)?
"Some mental health clients are unaware that they have a mental health condition." "Some mental health clients experience cognitive deficits and cannot understand their treatment plan." "Many mental health clients experience the effects of polypharmacy." "Many mental health clients experience worsening clinical manifestations."
a nurse is explaining the purpose of the family assessment device (FAD) to the parents of a child. which of the following statements by a parent indicates an understanding of the FAD?
"The FAD is used to help assess family functioning, specifically to determine how the roles of the family work in the family dynamics."
a nurse enters the day room, observes the clients, and performs a situational assessment. Which of the following situations should the nurse identify as the priority to address?
A client who is arguing with another client who is backed into a corner
a nurse is discussing the role of a licensed practical nurse (LPN) with a group of newly licensed nurses. which of the following statements by a newly licensed nurse indicates an understanding of the role of an LPN?
An LPN can report their observations to an RN."
a nurse is preparing to care for a client who is newly admitted. which of the following actions should the nurse take immediately?
address the clients aggressive behavior towards staff
a nurse is caring for a client and notes that the client has become increasingly restless over the last hour. This is an example of which of the following steps of the clinical judgement action model (CJAM)?
recognizing cues