Ch. 7 The Nursing Process and QSEN: The Foundation for Safe and Effective Care

Question 1

1. A new staff nurse completes orientation to the psychiatric unit. This nurse will expect to ask an advanced practice nurse to perform which action for patients?
   a. Perform mental health assessment interviews.
   b. Establish therapeutic relationships.
   c. Prescribe psychotropic medications.
   d. Individualize nursing care plans.

Answer 1

ANS: C
Prescriptive privileges are granted to Masters-prepared nurse practitioners who have taken special courses on prescribing medications. The nurse prepared at the basic level performs mental health assessments, establishes relationships, and provides individualized care planning.

Question 2

2. A newly admitted patient with major depressive disorder has lost 20 pounds over the past month and has suicidal ideation. The patient has taken an antidepressant medication for 1 week without remission of symptoms. Select the priority nursing diagnosis.
   a. Imbalanced nutrition: Less than body requirements
   b. Chronic low self-esteem
   c. Risk for suicide
   d. Hopelessness

Answer 2

ANS: C
Risk for suicide is the priority diagnosis when the patient has both suicidal ideation and a plan to carry out the suicidal intent. Imbalanced nutrition, Hopelessness, and Chronic low self-esteem may be applicable nursing diagnoses, but these problems do not affect patient safety as urgently as a suicide attempt.

Question 3

3. A patient with major depressive disorder has lost 20 pounds in one month has chronic low self-esteem and a plan for suicide. The patient has taken an antidepressant medication for 1 week. Which nursing intervention is most directly related to this outcome: Patient will refrain from gestures and attempts to harm self?
   a. Implement suicide precautions.
   b. Frequently offer high-calorie snacks and fluids.
   c. Assist the patient to identify three personal strengths.
   d. Observe patient for therapeutic effects of antidepressant medication.

Answer 3

ANS: A
Implementing suicide precautions is the only option related to patient safety. The other options, related to nutrition, self-esteem, and medication therapy, are important but are not priorities.

Question 4

4. A patients nursing diagnosis is Insomnia. The desired outcome is: Patient will sleep for a minimum of 5 hours nightly by October 31. On November 1, a review of the sleep data shows the patient sleeps an average of 4 hours nightly and takes a 2-hour afternoon nap. Which evaluation should be documented?
   a. Consistently demonstrated
   b. Often demonstrated
   c. Sometimes demonstrated
   d. Never demonstrated

Answer 4

ANS: D
Although the patient is sleeping 6 hours daily, the total is not in one uninterrupted session at night. Therefore the outcome must be evaluated as never demonstrated.

Question 5

5. A patients nursing diagnosis is Insomnia. The desired outcome is: Patient will sleep for a minimum of 5 hours nightly by October 31. On November 1, a review of the sleep data shows the patient sleeps an average of 4 hours nightly and takes a 2-hour afternoon nap. What is the nurses next action?
   a. Continue the current plan without changes.
   b. Remove this nursing diagnosis from the plan of care.
   c. Write a new nursing diagnosis that better reflects the problem.
   d. Revise the outcome target date and interventions.

Answer 5

ANS: D
Sleeping a total of 5 hours at night remains a reasonable outcome. Extending the time frame for attaining the outcome is appropriate. Examining interventions might result in planning an activity during the afternoon rather than permitting a nap. Continuing the current plan without changes is inappropriate. At the very least, the time in which the outcome is to be attained must be extended. Removing this nursing diagnosis from the plan of care could be used when the outcome goal has been met and the problem resolved. Writing a new nursing diagnosis is inappropriate because no other nursing diagnosis relates to the problem.

Question 6

6. 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?
   a. Assessment
   b. Analysis
   c. Planning
   d. Implementation
   e. Evaluation

Answer 6

ANS: D

Interventions are the nursing prescriptions to achieve the outcomes. Interventions should be specific.

Question 7

7. Before assessing a new patient, a nurse is told by another health care worker, I know that patient. No matter how hard we work, there isnt much improvement by the time of discharge. The nurses responsibility is to:
   a. document the other workers assessment of the patient.
   b. assess the patient based on data collected from all sources.
   c. validate the workers impression by contacting the patients significant other.
   d. discuss the workers impression with the patient during the assessment interview.

Answer 7

ANS: B
Assessment should include data obtained from both the primary and reliable secondary sources. Biased assessments by others should be evaluated as objectively as possible by the nurse, keeping in mind the possible effects of countertransference.

Question 8

8. A nurse works with a patient to establish outcomes. The nurse believes that one outcome suggested by the patient is not in the patients best interest. What is the nurses best action?
   a. Remain silent.
   b. Educate the patient that the outcome is not realistic.
   c. Explore with the patient possible consequences of the outcome.
   d. Formulate a more appropriate outcome without the patients input.

Answer 8

ANS: C
The nurse should not impose outcomes on the patient; however, the nurse has a responsibility to help the patient evaluate what is in his or her best interest. Exploring possible consequences is an acceptable approach.

Question 9

9. A patient states, Im not worth anything. I have negative thoughts about myself. I feel anxious and shaky all the time. Sometimes I feel so sad that I want to go to sleep and never wake up. Which nursing intervention should have the highest priority?
   a. Self-esteembuilding activities
   b. Anxiety self-control measures
   c. Sleep enhancement activities
   d. Suicide precautions

Answer 9

ANS: D
The nurse should place priority on monitoring and reinforcing suicide self-restraint because it relates directly and immediately to patient safety. Patient safety is always a priority concern. The nurse should monitor and reinforce all patient attempts to control anxiety, improve sleep patterns, and develop self-esteem while giving priority attention to suicide self-restraint.

Question 10

10. Select the best outcome for a patient with this nursing diagnosis: Impaired social interaction, related to sociocultural dissonance as evidenced by stating, Although Id like to, I dont join in because I dont speak the language very well. The patient will:
    a. demonstrate improved social skills.
    b. express a desire to interact with others.
    c. become more independent in decision making.
    d. select and participate in one group activity per day.

Answer 10

ANS: D
The outcome describes social involvement on the part of the patient. Neither cooperation nor independence has been an issue. The patient has already expressed a desire to interact with others. Outcomes must be measurable. Two of the distractors are not measurable.

Question 11

11. Nursing behaviors associated with the implementation phase of the nursing process are concerned with:
    a. participating in the mutual identification of patient outcomes.
    b. gathering accurate and sufficient patient-centered data.
    c. comparing patient responses and expected outcomes.
    d. carrying out interventions and coordinating care.

Answer 11

ANS: D
Nursing behaviors relating to implementation include using available resources, performing interventions, finding alternatives when necessary, and coordinating care with other team members.

Question 12

12. Which statement made by a patient during an initial assessment interview should serve as the priority focus for the plan of care?
    a. I can always trust my family.
    b. It seems like I always have bad luck.
    c. You never know who will turn against you.
    d. I hear evil voices that tell me to do bad things

Answer 12

ANS: D
The statement regarding evil voices tells the nurse that the patient is experiencing auditory hallucinations. The other statements are vague and do not clearly identify the patients chief symptom.

Question 13

13. Which entry in the medical record best meets the requirement for problem-oriented charting?
    a. A: Pacing and muttering to self. P: Sensory perceptual alteration, related to internal auditory stimulation. I: Given fluphenazine (Prolixin) 2.5 mg at 0900, and went to room to lie down. E: Calmer by 0930. Returned to lounge to watch TV.
    b. S: States, I feel like Im ready to blow up. O: Pacing hall, mumbling to self. A: Auditory hallucinations. P: Offer haloperidol (Haldol) 2 mg. I: (Haldol) 2 mg at 0900. E: Returned to lounge at 0930 and quietly watched TV.
    c. Agitated behavior. D: Patient muttering to self as though answering an unseen person. A: Given haloperidol (Haldol) 2 mg and went to room to lie down. E: Patient calmer. Returned to lounge to watch TV.
    d. Pacing hall and muttering to self as though answering an unseen person. haloperidol (Haldol) 2 mg administered at 0900 with calming effect in 30 minutes. Stated, Im no longer bothered by the voices.

Answer 13

ANS: B
Problem-oriented documentation uses the first letter of key words to organize data: S for subjective data, O for objective data, A for assessment, P for plan, I for intervention, and E for evaluation. The distractors offer examples of PIE charting, focus documentation, and narrative documentation.

Question 14

14. A nurse assesses an older adult patient brought to the emergency department by a family member. The patient was wandering outside, saying, I cant find my way home. The patient is confused and unable to answer questions. Select the nurses best action.
    a. Document the patients mental status. Obtain other assessment data from the family member.
    b. Record the patients answers to questions on the nursing assessment form.
    c. Ask an advanced practice nurse to perform the assessment interview.
    d. Call for a mental health advocate to maintain the patients rights.

Answer 14

ANS: A
When the patient (primary source) is unable to provide information, secondary sources should be used, in this case the family member. Later, more data may be obtained from other relatives or neighbors who are familiar with the patient. An advanced practice nurse is not needed for this assessment; it is within the scope of practice of the staff nurse. Calling a mental health advocate is unnecessary.

Question 15

15. A nurse asks a patient, If you had fever and vomiting for 3 days, what would you do? Which aspect of the mental status examination is the nurse assessing?
    a. Behavior
    b. Cognition
    c. Affect and mood
    d. Perceptual disturbances

Answer 15

ANS: B
Assessing cognition involves determining a patients judgment and decision-making capabilities. In this case, the nurse expects a response of Call my doctor if the patients cognition and judgment are intact. If the patient responds, I would stop eating, or I would just wait and see what happened, the nurse would conclude that judgment is impaired. The other options refer to other aspects of the examination.

Question 16

16. An adolescent asks a nurse conducting an assessment interview, Why should I tell you anything? Youll just tell my parents whatever you find out. Select the nurses best reply.
    a. That is not true. What you tell us is private and held in strict confidence. Your parents have no right to know.
    b. Yes, your parents may find out what you say, but it is important that they know about your problems.
    c. What you say about feelings is private, but some things, like suicidal thinking, must be reported to the treatment team.
    d. It sounds as though you are not really ready to work on your problems and make changes.

Answer 16

ANS: C
The patient has a right to know that most information will be held in confidence but that certain material must be reported or shared with the treatment team, such as threats of suicide, homicide, use of illegal drugs, or issues of abuse. The first response is not strictly true. The second response will not inspire the confidence of the patient. The fourth response is confrontational.

Question 17

17. A nurse assessing a new patient asks, What is meant by the saying, You cant judge a book by its cover? Which aspect of cognition is the nurse assessing?
    a. Mood
    b. Attention
    c. Orientation
    d. Abstraction

Answer 17

ANS: D
Patient interpretation of proverbial statements gives assessment information regarding the patients ability to abstract, which is an aspect of cognition. Mood, orientation, and attention span are assessed in other ways.

Question 18

18. When a nurse assesses an older adult patient, the patients answers seem vague or unrelated to the questions. The patient also leans forward and frowns, listening intently to the nurse. An appropriate question for the nurse to ask would be:
    a. Are you having difficulty hearing when I speak?
    b. How can I make this assessment interview easier for you?
    c. I notice you are frowning. Are you feeling annoyed with me?
    d. Youre having trouble focusing on what Im saying. What is distracting you?

Answer 18

ANS: A
The patients behaviors may indicate difficulty hearing. Identifying any physical need the patient may have at the onset of the interview and making accommodations are important considerations. By asking if the patient is annoyed, the nurse is jumping to conclusions. Asking how to make the interview easier for the patient may not elicit a concrete answer. Asking about distractions is a way of asking about auditory hallucinations, which is not appropriate because the nurse has observed that the patient seems to be listening intently.

Question 19

19. At one point in an assessment interview a nurse asks, How does your faith help you in stressful situations? This question would be asked during the assessment of:
    a. childhood growth and development.
    b. substance use and abuse.
    c. educational background.
    d. coping strategies.

Answer 19

ANS: D
When discussing coping strategies, the nurse might ask what the patient does when upset, what usually relieves stress, and to whom the patient goes to talk about problems. The question regarding whether the patients faith helps deal with stress fits well here. It would seem out of place if introduced during exploration of the other topics.

Question 20

20. When a new patient is hospitalized, a nurse takes the patient on a tour, explains the rules of the unit, and discusses the daily schedule. The nurse is engaged in:
    a. counseling.
    b. health teaching.
    c. milieu management.
    d. psychobiologic intervention.

Answer 20

ANS: C
Milieu management provides a therapeutic environment in which the patient can feel comfortable and safe while engaging in activities that meet the patients physical and mental health needs. Counseling refers to activities designed to promote problem solving and enhanced coping and includes interviewing, crisis intervention, stress management, and conflict resolution. Health teaching involves identifying health educational needs and giving information about these needs. Psychobiologic interventions involve medication administration and monitoring response to medications.

Question 21

21. After formulating the nursing diagnoses for a new patient, what is the next action a nurse should take?
    a. Design interventions to include in the plan of care.
    b. Determine the goals and outcome criteria.
    c. Implement the nursing plan of care.
    d. Complete the spiritual assessment.

Answer 21

ANS: B
The third step of the nursing process is planning and outcome identification. Outcomes cannot be determined until the nursing assessment is complete and the nursing diagnoses have been formulated.

Question 22

22. Select the most appropriate label to complete this nursing diagnosis: ___________, related to feelings of shyness and poorly developed social skills as evidenced by watching television alone at home every evening.
    a. Deficient knowledge
    b. Ineffective coping
    c. Powerlessness
    d. Social isolation

Answer 22

ANS: D
Nursing diagnoses are selected on the basis of the etiologic factors and assessment findings or evidence. In this instance, the evidence shows social isolation that is caused by shyness and poorly developed social skills.

Question 23

23. The acronym QSEN refers to:
    a. Qualitative Standardized Excellence in Nursing.
    b. Quality and Safety Education for Nurses.
    c. Quantitative Effectiveness in Nursing.
    d. Quick Standards Essential for Nurses.

Answer 23

ANS: B
QSEN represents national initiatives centered on patient safety and quality. The primary goal of QSEN is to prepare future nurses with the knowledge, skills, and attitudes to increase the quality, care, and safety in the health care setting in which they work.

Question 24

24. A nurse documents: Patient is mute, despite repeated efforts to elicit speech. Makes no eye contact. Is inattentive to staff. Gazes off to the side or looks upward rather than at the speaker. Which nursing diagnosis should be considered?
    a. Defensive coping
    b. Decisional conflict
    c. Risk for other-directed violence
    d. Impaired verbal communication

Answer 24

ANS: D
The defining characteristics are more related to the nursing diagnosis of Impaired verbal communication than to the other nursing diagnoses.

Question 25

1. A nurse assesses a patient who reluctantly participates in activities, answers questions with minimal responses, and rarely makes eye contact. What information should be included when documenting the assessment? Select all that apply.
   a. Uncooperative patient
   b. Patients subjective responses
   c. Only data obtained from the patients verbal responses
   d. Description of the patients behavior during the interview
   e. Analysis of why the patient is unresponsive during the interview

Answer 25

ANS: B, D
Both the content and process of the interview should be documented. Providing only the patients verbal responses creates a skewed picture of the patient. Writing that the patient is uncooperative is subjectively worded. An objective description of patient behavior is preferable. Analysis of the reasons for the patients behavior is speculation, which is inappropriate.

Question 26

2. A nurse performing an assessment interview for a patient with a substance abuse disorder decides to use a standardized rating scale. Which scales are appropriate? Select all that apply.
   a. Addiction Severity Index (ASI)
   b. Brief Drug Abuse Screen Test (B-DAST)
   c. Abnormal Involuntary Movement Scale (AIMS)
   d. Cognitive Capacity Screening Examination (CCSE)
   e. Recovery Attitude and Treatment Evaluator (RAATE)

Answer 26

ANS: A, B, E
Standardized scales are useful for obtaining data concerning substance use disorders. The ASI, B-DAST, and RAATE are scales related to substance abuse. The AIMS assesses involuntary movements associated with antipsychotic medications. The CCSE assesses cognitive function.

Question 27

3. What information is conveyed by nursing diagnoses? Select all that apply.
   a. Medical judgments about the disorder
   b. Goals and outcomes for the plan of care
   c. Unmet patient needs currently present
   d. Supporting data that validate the diagnoses
   e. Probable causes that will be targets for nursing interventions

Answer 27

ANS: C, D, E
Nursing diagnoses focus on phenomena of concern to nurses rather than on medical diagnoses. Goals and outcomes are part of the planning phase.

Question 28

4. A patient is very suspicious and states, The FBI has me under surveillance. Which strategies should a nurse use when gathering initial assessment data about this patient? Select all that apply.
   a. Tell the patient that medication will help this type of thinking.
   b. Ask the patient, Tell me about the problem as you see it.
   c. Seek information about when the problem began.
   d. Tell the patient, Your ideas are not realistic.
   e. Reassure the patient, You are safe here.

Answer 28

ANS: B, C, E
During the assessment interview, the nurse should listen attentively and accept the patients statements in a nonjudgmental way. Because the patient is suspicious and fearful, reassuring safety may be helpful, although trust is unlikely so early in the relationship. Saying that medication will help or telling the patient that the ideas are not realistic will undermine the development of trust between the nurse and patient.