7 (Nursing Process & Standards of Care) Flashcards
You are conducting an admission interview with Callie, who was raped 2 weeks ago. When you ask Callie about the rape, she becomes very anxious and upset and begins to sob. Your best course of actions would be to:
a. ) push Callie gently for more information about the rape because you need to document this in her chart.
b. ) acknowledge that the topic of the rape is upsetting to Callie and reassure her that it can be discussed at another time when she feels more comfortable.
c. ) use silence as a therapeutic tool and wait until Callie is done sobbing to continue discussing the rape.
d. ) reassure Callie that anything she says to you will remain confidential.
b.) acknowledge that the topic of the rape is upsetting to Callie and reassure her 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 patient’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 patient to discuss.
The use of silence continues to expect the patient to discuss the topic now. Reassurance of confidentiality continues to expect the patient to discuss the topic now.
You are interviewing Jamie, a 17-year-old female patient. She confides that she has been thinking of ways to kill a female peer who is Jamie’s rival for the volleyball team captain position. She asks you if you can keep it a secret. The most appropriate response for you to make is:
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. ) “Jamie, issues of this kind have to be shared with the treatment team and your parents.”
d. ) “Jamie, I will have to share this with the treatment team, but we will not share it with your parents.”
c.) “Jamie, issues of this kind have to be shared with the treatment team and your parents.”
Although adolescent patients request confidentiality, issues of sexual abuse, threats of suicide or homicide, or issues that put the patient 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 patient or others. This information would be shared with both the team and the parents.
Which response to a patient’s question of why you need to conduct an assessment interview best explains its purpose?
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.”
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.
Joel is a 43-year-old patient being seen in the mental health clinic with depression. Joel 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 Joel’s comment?
a. ) Ineffective coping
b. ) Spiritual distress
c. ) Risk for self-harm
d. ) Hopelessness
b.) Spiritual distress
Joel is expressing distress regarding his religion and spiritual well-being.
Joel could be experiencing ineffective coping, but this does not directly relate to his comment.
There is nothing in Joel’s comment that would lead to the conclusion the patient is having thoughts of harming himself.
Joel’s comment does not describe hopelessness.
You are working in the emergency department when a 26-year-old male patient is brought in suffering from psychosis. The patient is unable to give any coherent history. The patient’s best friend is with him and offers to give you information regarding the patient. Which of the following responses is appropriate?
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.”
The friend is a secondary source of information that will be helpful since the patient 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 patient from a secondary source, and a psychotic patient would not be competent to sign a release.
In psychiatric nursing, assessment of a “client” refers exclusively to
a. ) an individual with a psychiatric diagnosis.
b. ) an individual, family, group, or community.
c. ) any person who seeks the assistance of the psychiatric nurse.
d. ) the person identified by the system as being in need of treatment.
b.) an individual, family, group, or community.
Standards of practice for psychiatric nursing indicate that the client can be an individual, a family, a group, or a community.
What three structural components comprise a nursing diagnosis?
a. ) Problem, outcome, intervention
b. ) Problem, etiology, supporting data
c. ) Unmet need, goal, outcome criterion
d. ) Presenting symptom, treatment, goal
b.) Problem, etiology, supporting data
The components of the nursing diagnosis are problem, etiology, and supporting data.
The mental status examination aids in the collection of what type of data?
a. ) Covert
b. ) Physical
c. ) Objective
d. ) Subjective
c.) Objective
The mental status exam mostly aids in the collection of objective data.
What is the common behavior shared by both client and nurse at the beginning of the initial assessment interview?
a. ) Anxiety
b. ) Biased perceptions
c. ) Countertransference
d. ) Reliance on supportive confrontation
a.) Anxiety
Both parties feel at least a small amount of anxiety associated with interacting with an unknown person.
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, the etiology, and supporting data.
The client’s priority nursing diagnosis has been established as risk for self-directed violence: suicide related to multiple losses. The priority outcome would be that the client will
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.
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.
