Unit 1 Nursing Process Chapter 7

Question 1

What is the Nursing Process?

Answer 1

Assessment
Diagnostics
Outcome Identification
Planning
Implementation(Intervention)
Evaluation

Question 2

The purpose of the Psychiatric–mental health nursing assess- ment is to..

Answer 2

The purpose of the psychiatric–mental health nursing assess- ment is to
* Establish rapport
* Obtain an understanding of the current problem or chief
complaint
* Review the patient’s physical status and obtain baseline vital
signs
* Assess for risk factors affecting the safety of the patient or
others
* Perform a mental status examination
* Assess psychosocial status
* Identify mutual goals for treatment
* Formulate a plan of care
* Document data in a retrievable format

Question 3

Assessment, consist of

Answer 3

— Mental status examination
(MSE)
— Psychosocial assessment — Physical examination
— History taking
— Interviews
— Standardized rating scales
* Verify the data

Question 4

Diagnoses, consist of

Answer 4

Identify problem and etiology
* Construct nursing diagnoses
and problem list
* Prioritize nursing diagnoses

Question 5

Outcome Identification

Answer 5

• Identify attainable and culturally expected outcomes
• Document expected outcomes as measurable goals
• Include time estimate for expected outcomes

Question 6

Planning, consist of

Answer 6

• Identify safe, pertinent, evidence-based actions
• Strive to use interventions that are culturally relevant and compatible with health beliefs and practices
• Document plan using recognized terminology

Question 7

Implementation

Answer 7

Basic Level Interventions:
* Coordination of care
* Health teaching and health
promotion
* Milieu therapy
* Pharmacological, biological,
and integrative therapies
Advanced Practice Interventions: * Prescriptive authority and
treatment
* Psychotherapy * Consultation

Question 8

Evaluation

Answer 8

• Document results of evaluation
• If outcomes have not been
  achieved at desired level:
  — Additional data gathering — Reassessment
  — Revision of plan

Question 9

Which part of the nursing process does the Mental status examination (MSE) takes place?

A. Planning
B. Evaluation
C. Assessment
D. Outcome Identification

Answer 9

C. Assessment

Question 10

Whatpart of the nursing process is primary and secondary data collected?
A. Planning
B. Evaluation
C. Assessment
D. Outcome Identification

Answer 10

C. Assessment

Question 11

After all planning and implementations are complete for a patient suffering with suicidal ideation. What is the Interdiscplinary’s team next action?

A. Assess the patient with a Mental Status Exam (MSE).
B. Evaluate all measures that were to complete to assure the effectiveness of the plan of care.
C. Speak to the patient to provide patient Centured Care.
D. Discharge the patient.

Answer 11

B. Evaluate all measures that were to complete to assure the effectiveness of the plan of care.

Question 12

What is Primary data?

Answer 12

In patient-centered care, the nurse’s primary source of data is the patient.

Question 13

What is Secondary Data?

Answer 13

secondary sources include members of the family, friends, neighbors, police, healthcare workers, and medical records.

Question 14

Your psychiatric patient is alert and oriented and conscious to time, place, and name. You completed your interview with the patient and received a call from the patients family suggesting that the patient does not know what mental disorder that they currently have. What is the nurses priority action?

A. Conduct further investigation on what the patient’s family is stating.
B. Prioritize the patient’s past medical history and primary data over families subjective data.
C. Agree with the family and prioritize secondary data.

Answer 14

B. Prioritize the patient’s past medical history and primary data over families subjective data.

Question 15

When is the only time should you prioritize Secondary data?

A. When the patient has visual impairment.
B. When the patient is conscious.
C. When the patient is silent
D. When the patient is talkative

Answer 15

C. When the patient is silent

These secondary sources are essential when the nurse is caring for a patient who is silent or is experienc- ing psychosis, agitation, or catatonia. Such secondary sources include members of the family, friends, neighbors, police, healthcare workers, and medical records.

Question 16

Which of the following laws was created to improve the safety and quality of care for patients?

A. Mental Parity Act
B. Affordable Care Act
C. Quality and Safety Education for Nurses(QSEN)
D. Health Insurance Portability and Accountability Act(HIPAA)

Answer 16

Quality and Safety Education for Nurses

Question 17

What is required for all healthcare workers to follow under the Quality and Safety Education for Nurses Law ( Institute of Medicine sought to improve quality and safety of care)

Answer 17

All healthcare workers must:
* Provide patient-centered care
* Work in interdisciplinary teams
* Employ evidence-based practice
* Apply quality improvement
* Utilize informatics

Question 18

When initiating an assessment on a child what is the priority action?

Answer 18

observe the patients actions and interaction with parent

Question 19

When you are assessing a child , who would you rely on for the best source of understanding the Childs inner feelings and emotion?

A. Child
B. Parents
C. Psychiatric Doctor
D. Psychiatric Nurse

Answer 19

A. Child

Although the child is the best source for understanding the child’s inner feelings and emotions, the caregivers (parents or guardians) can often best describe the child’s behavior, performance, and conduct.

Question 20

Which of the following is the best way to engage a child in an interview who has difficulty verbally communicating?

A. Initiating play such as drawing a picture or playing with toys.
B. Asking parents to complete interview for child.
C. Acknowledging that the child may not want to revisit said experience and dismissing the interview.
D. Calling in the entire department to get the child to talk.

Answer 20

A. Initiating play such as drawing a picture or playing with toys.

Children are assessed through a combination of interview and observation.

Watching children at play provides important clues to their functioning.

*Play is a safe area for children to act out thoughts and emotions.

*Asking the child to tell a story, *draw a picture, or engage in specific therapeutic games can be useful, particularly when the child is having difficulty with verbal expression.

Question 21

You are conducting an interview on a 7 year old child with their parent in the room. The child is reluctant to share information. What is the nurses priority action?

A. Conduct the interview, with the child parent , and bringing in a witness.
B. Separating the child from the mother to continue conducting the interview.
C. Advice that the mom encourages the child to speak about an event.
D. Dismiss the interview due to the child’s high anxiety level.

Answer 21

B. Separating the child from the mother to continue conducting the interview.

Caregivers are also helpful in interpreting the child’s words and responses, but a separate interview is advisable when a child is reluctant to share information, especially in cases of suspected abuse by the parents or guardians.

Question 22

Your 16 year old patient has been crying hourly for their mother. They are constantly yelling I can’t do this without my mom , I need my mom”. What psychiatric disorder do you suspect this child to be displaying?

A. Sublimation
B. Projection
C. Repression
D. Regression

Answer 22

D. Regression

One of the hallmarks of psychiatric disorders in children is the tendency to regress

(i.e., return to a previous level of develop- ment). For example, although it is developmentally appropriate for toddlers to suck their thumbs, such a gesture is unusual in an older child.

Question 23

What is priority when providing care for Adolescents?

Answer 23

Adolescents are especially concerned with confidentiality and may fear that you will repeat what they say to their parents.

CONFIDENTILIATY

Question 24

What is the function of the HEADSSS interview for Adolescents

Answer 24

One of the key objectives in the assessment of adolescents is the identification of risk factors of mental illness. It is helpful to use a brief structured interview technique such as the HEADSSS interview

Question 25

HEADSSS Assement tool

Answer 25

H-Home environment (e.g., relations with parents and siblings)

E-Education and employment (e.g., school performance)

A-Activities (e.g., sports participation, after-school activities, peer relations)

D-Drug, alcohol, or tobacco use

S-Sexuality (e.g., whether the patient is sexually active, practices safe sex, or
uses contraception)

S-Suicide risk or symptoms of depression or other mental disorder

S-Safety (e.g., how safe does the patient feel at home and school, wear a safety belt, or engage in dangerous or risky activities)

Question 26

What should be shared to the parents of the adolescent patient.

Answer 26

Threats of suicide, homicide, sexual abuse, or behaviors that put the patient or others at risk for harm are shared with other pro- fessionals as well as with the parents.

Question 27

Older Adults Assessment- Nursing Considerations

Answer 27

Older Adults
* Don’t stereotype – Rule out Medical Cause
* Be aware of any physical limitation
* Sensory or motor deficits, physical illness (increase anxiety, stress, pain)

*It is wise to identify physical deficits at the onset of the assessment and to make accommodations for them.

example; if your elderly patient has a hearing loss due to age , DONT SPEAK FAST AND LOUDLY

Sometimes healthcare providers will speak loudly to an older adult, regard- less of the patient’s hearing ability. You can usually gauge the amount, if any, of hearing loss after a few sentences. If the patient is hard of hearing, speak a little more slowly in clear, louder tones (but not too loud). Without invading personal space, seat the patient close to you. Often, a voice that is lower in pitch is easier for older adults to hear.

Question 28

Spiritual Asseessment taht psych nurses may ask patients.

Answer 28

The following types of questions are included in a spiritual or religious assessment:
* Do you have a religious affiliation?
* Do you practice any spiritual activities (e.g., yoga, medita-
tion, spending time in nature)?
* Do you participate in any religious activities?
* What role does religion or spiritual practice play in your life?
* Does your faith help you in stressful situations?
* * *
Do you pray or meditate?
Has your illness affected your religious/spiritual practices? Would you like to have someone from your church/syna- gogue/temple or from our facility visit you?

Question 29

Cultural Assessment questions during interview

Answer 29

• What is your primary language? Would you like an interpreter?
• How would you describe your cultural background?
• Who are you close to?
• Who do you live with?
• How is your family responding to your treatment?
• Where do you go when you are physically ill? Emotionally
  upset or concerned?
• What do you do to get better when you have physical prob-
  lems?
• What are the attitudes toward mental illness in your culture?
• How is your current problem viewed by your culture? Is it
  seen as a problem that can be fixed? A disease? A taboo? A
  fault or curse?
• Are there special foods that you eat or cannot eat?
• Are there special healthcare practices within your culture
  that address your particular mental or emotional health
  problem?
• Are there any special cultural beliefs about your illness that
  might help me give you better care?

Question 30

Importance of Psychosocial assessment

Answer 30

A psychosocial assessment provides additional information from which to develop a plan of care.

This type of assessment always begins by asking the patient to describe how treatment became necessary.

This is known as the chief complaint and should be documented verbatim, that is, in the patient’s own words; for example, “I have been completely miserable and alone since my husband died.”

Question 31

Mental Status Exam Categories

Answer 31

*Appearance
* Behavior
* Speech
* Mood
* D/O of the form of thought
* Perceptual Disturbances
* Cognition
*Ideas of Harming Self or Others

Question 32

What does Appearance consist of in MSE

Answer 32

APPEARANCE

Grooming and dress
* Level of hygiene
* Pupil dilation or constriction
* Facial expression
* Height, weight, nutritional status
* Presence of body piercing or tattoos, scars, etc.
* Relationship between appearance and age

Question 33

What does Behavior consist of in MSE

Answer 33

• Excessive or reduced body movements
• Peculiar body movements (e.g., scanning of the environment, odd or repeti-
  tive gestures, level of consciousness, balance, and gait)
• Abnormal movements (e.g., tardive dyskinesia, tremors)
• Level of eye contact (keep cultural differences in mind)

Question 34

What does Speech consist of in MSE

Answer 34

• Rate: slow, rapid, normal
• Volume: loud, soft, normal
• Disturbances (e.g., articulation problems, slurring, stuttering, mumbling)

Question 35

What does Mood consist of in MSE

Answer 35

• Affect: flat, bland, animated, angry, withdrawn, appropriate to context(how the patient looks and what the nurse observes)
• Mood: sad, labile, euphoric(subjective , what the patient says)

Question 36

What does the Disorder of the Form of thought consist of in MSE

Answer 36

• Thought process (e.g., disorganized, coherent, flight of ideas, neologisms, thought blocking, circumstantiality)

example- I just got my nails done at a factory that sells goldfish. I hate goldfish but I love bones

• Thought content (e.g., delusions, obsessions)

ex, I’m in love with Justin Berber he sleeps with me everynight

Question 37

What does Perceptual Disturbances consist of in MSE

Answer 37

• Hallucinations (e.g., auditory, visual)
• Illusions(ONLY VISUAL)

Question 38

What does Cognition consist of in MSE

Answer 38

• Orientation: time, place, person
• Level of consciousness (e.g., alert, confused, clouded, stuporous, uncon-
  scious, comatose)
• Memory: remote, recent, immediate
• Fund of knowledge
• Attention: performance on serial sevens, digit span tests
• Abstraction: performance on tests involving similarities, proverbs
• Insight
• Judgment

Question 39

What does Ideas of Harming Self or Others consist of in MSE

Answer 39

• Suicidal or homicidal history and current thoughts
• Presence of a plan
• Means to carry out the plan
• Opportunity to carry out the plan

Question 40

Is religion or spirituality a more broader concept?

Answer 40

spirituality

Question 41

Key intervention for language barriers

Answer 41

Often healthcare professionals require an interpreter or translator to understand the patient’s history and healthcare needs. An interpreter is someone who interprets the spoken words of a foreign language speaking person or someone who uses American Sign Language (ASL).

” do you need an interpreter”

Question 42

Nursing diagnoses, Outcome, and planning examples

Answer 42

Nursing Diagnosis
* Problem/Potential problem
* Related Factors
* Defining Characteristics

• Ineffective Copping related to alcohol abuse as evidence by patient stating “I drink when I’m
  stressed and depressed. It takes the edge off.”
• Outcomes – reflect maximum level of patient health
• Planning – Safe, appropriate, realistic, individualized, Evidence based

Question 43

Narrative Charting Characteristic

Answer 43

STORY TELLING

A descriptive statement of patient status written in chronological order throughout a shift. Used to support assessment findings from a flow sheet. In charting by exception, narrative notes are used to indicate significant symptoms, behaviors, or events that are exceptions to norms identified on an assessment flow sheet.

Question 44

Narrative Charting Example

Answer 44

(Date/time/discipline)
*Patient was agitated in the morning and pacing in the hallway. *Blinked eyes, muttered to self, and looked off to the side. *Reported heard voices.
*Verbally hostile to another patient.
*Offered 2 mg haloperidol (Haldol) PRN and sat with staff in quiet
area for 20 min.
*Patient returned to community lounge and was able to sit and
watch television.

Question 45

Narrative Charting Advantages

Answer 45

*Uses a common form of expression (narrative writing).
*Can address any event or behavior.
*Explains flow-sheet findings.
*Provides multidisciplinary ease of use.
*Choronological order: starting with the earliest and following the order in which they occurred.

Question 46

Narrative Charting Disadvantages

Answer 46

*Unstructured.
*May result in different organization of information from note to
note.
*Makes it difficult to retrieve quality assurance and utilization
management data.
*Frequently leads to omission of elements of the nursing process. *Commonly results in inclusion of unnecessary and subjective
information.

Question 47

SOAPIE Characteristics

Answer 47

S: Subjective data (patient statement)
O: Objective data (nurse observations)
A: Assessment (nurse interprets S and O and describes either a problem or a
nursing diagnosis)
P: Plan (proposed intervention)
I: Interventions (nurse’s response to problem) E: Evaluation (patient outcome)

Question 48

SOAPIE Example

Answer 48

Date/time/discipline)
S: “I’m so stupid. Get away, get away.” “I hear the devil telling me bad things.”

O: Patient paced the hall, mumbling to self, and looking off to the side. Shouted
insulting comments when approached by another patient. Watched walls and
ceiling closely.
A: Patient was having auditory hallucinations and increased agitation.
P: Offered patient haloperidol PRN. Redirected patient to less stimulating
environment.
I: Patient received 2 mg haloperidol PO PRN. Sat with patient in quiet room for
20 min.
E: Patient calmer. Returned to community lounge, sat, and watched television.

Question 49

SOAPIE Advantages

Answer 49

*Structured.
*Provides consistent organization of data.
*Facilitates retrieval of data for quality assurance and utilization management.
*Contains all elements of the nursing process.
*Minimizes inclusion of unnecessary data.
*Provides multidisciplinary ease of use.

Question 50

SOAPIE Disadvantages

Answer 50

*Requires time and effort to structure the information. (TIME CONSUMING)
*Limits entries to problems.
*May result in loss of data about progress.
*Not chronological.
*Carries negative connotation.

Question 51

Legal Considerations Do’s (Documentation)

Answer 51

Do
* Chart in a timely manner all pertinent and factual information.
* Follow the nursing documentation policy in your facility and make your charting conform to this standard. The policy generally states the method, frequency, and assessments, interventions, and outcomes to be recorded. If your agency’s policies and procedures do not encourage or allow for quality
documentation, bring the need for change to the administration’s attention.
* Chart facts fully, descriptively, and accurately.
* Chart what you see, hear, feel, and smell.
* Chart observations: psychosocial interactions, physical symptoms, and behav-
iors.
* Chart follow-up care provided when a problem has been identified in earlier
documentation. For example, if a patient has fallen and injured a leg, describe
how the wound is healing.
* Chart fully the facts surrounding unusual occurrences and incidents.
* Chart all nursing interventions, treatments, and outcomes (including teaching
and patient responses) and safety and patient-protection interventions.
* Chart the patient’s subjective feelings and symptoms.
* Chart each time you notify the advanced practice provider and record the rea-
son for notification, the information that was communicated, the time, the provider’s instructions or orders, and the follow-up activity.
*Chart discharge medications and instructions given for their use, as well as all discharge teaching, and note if family members included in the process.

Question 52

Legal Considerations Don’t (Documentation

Answer 52

Do Not
* Do not chart opinions that are not supported by facts.
* Do not defame patients by calling them names or making derogatory state-
ments about them (e.g., “an unlikable patient who is demanding unnecessary
attention”).
* Do not chart before an event occurs.
* Do not chart generalizations, suppositions, or pat phrases (e.g., “patient in
good spirits”).
* Do not obliterate, erase, alter, or destroy a record. If an error is made, draw
one line through the error, write “mistaken entry,” the date, and initial. Follow
your agency’s guidelines for mistakes.
* Do not leave blank spaces for chronological notes. If you must chart out of
sequence, chart “late entry.” Identify the time and date of the entry and the
time and date of the occurrence.
* If an incident report is filed, do not note in the chart that one was filed. This
form is generally a privileged communication between the hospital and the hospital’s legal team. Describing it in the chart may eliminate the privileged nature of the communication.

Question 53

What should documentation include?

Answer 53

Whatever format is used, documentation must be focused, organized, pertinent, and conform to certain legal and other generally accepted principles

Do Chart – Timely, facts, descriptive, pertinent observations, Subjective data (patient’s
feelings, thoughts)

Question 54

A nurse assesses an older adult client brought to the emergency department (ED) by a family member. The client was wandering outside saying, “I can’t find my way home.” The client is confused and unable to answer questions. Select the nurse’s best action.
a. Record the client’s answers to questions on the nursing assessment form.
b. Ask an advanced practice nurse to perform the assessment interview.
c. Call for a mental health advocate to maintain the client’s rights.
d. Obtain important information from the family member.

Answer 54

ANS: D
When the client (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 information sources familiar with the client. 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. See relationship to audience response question.

Question 55

A nurse asks a client, “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 55

ANS: B
Assessing cognition involves determining a client’s judgment and decision making. In this case, the nurse would expect a response of “Call my doctor” if the client’s cognition and judgment are intact. If the client 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 56

An adolescent asks a nurse conducting an assessment interview, “Why should I tell you anything? You’ll just tell my parents whatever you find out.” Which response by the nurse is appropriate?
a. “That isn’t 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 56

ANS: C
Adolescents are very concerned with confidentiality. The client 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 incorrect responses are not true, will not inspire the confidence of the client, or are confrontational.

Question 57

Importance of Milieu management

Answer 57

Milieu management provides a therapeutic environment in which the client can feel comfortable and safe while engaging in activities that meet the client’s physical and mental health needs.

Question 58

What does “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 58

ANS: B
QSEN represents national initiatives centered on client 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 59

QSEN ,( Quality of safety and Education for Nurses) question (select all that apply)

Answer 59

QSEN ,( Quality of safety and Education for Nurses) question (select all that apply)
-Provide patient-centered care
-Work in interdisciplinary teams
-Employ evidence-based practice
-Apply quality improvement
- Utilize informatics