Question: A nurse works with a patient to establish outcomes. The nurse believes that one outcome suggested by the patient is not in the patient’s best interest. What is the nurse’s best action?
Answer Choices: 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 patient’s input.
Answer: C
Question: A patient states, “I’m 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?
Answer Choices: a. Self-esteem-building activities b. Anxiety self-control measures c. Sleep enhancement activities d. Suicide prevention
Answer: D
Question: Select the best outcome for a patient with this nursing diagnosis: impaired social interaction, related to sociocultural dissonance as evidenced by stating, “Although I’d like to, I don’t join in because I don’t speak the language very well.” What should the focus of an appropriate outcome be?
Answer Choices: a. Demonstrating improved social skills b. Expressing a desire to interact with others c. Becoming more independent in decision making d. Selecting and participating in one group activity per day
Answer: D
Question: Nursing behaviors associated with the implementation phase of the nursing process are concerned with the responsibilities of the psychiatric mental health nurse?
Answer Choices: 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: D
Question: Which statement made by a patient during an initial assessment interview should serve as the priority focus for the plan of care?
Answer Choices: 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: D
Question: Which entry in the medical record best meets the requirement for problem-oriented charting?
Answer Choices: a. “A: Pacing and muttering to self. P: Sensory perceptual alteration, related to internal auditory stimulation. I: Given fluphenazine 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 I’m ready to blow up.’ O: Pacing hall, mumbling to self. A: Auditory hallucinations. P: Offer haloperidol 2 mg. I: haloperidol 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 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 2 mg administered at 0900 with calming effect in 30 minutes. Stated, ‘I’m no longer bothered by the voices.’”
Answer: B
Question: A nurse assesses an older adult patient brought to the emergency department by a family member. The patient was wandering outside, saying, “I can’t find my way home.” The patient is confused and unable to answer questions. What is the nurse’s best action to provide effective nursing care?
Answer Choices: a. Document the patient’s mental status. Obtain other assessment data from the family member. b. Record the patient’s 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 patient’s rights.
Answer: A
Question: 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?
Answer Choices: a. Behavior b. Cognition
Answer: B
Question: 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.” What is the nurse’s best reply regarding patient confidentiality?
Answer Choices: 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: C
Question: A nurse assessing a new patient asks, “What is meant by the saying, ‘You can’t judge a book by looking at the cover?’” Which aspect of cognition is the nurse assessing?
Answer Choices: a. Mood b. Attention c. Orientation d. Abstraction
Answer: D
Question: When a nurse assesses an older adult patient, and the patient’s answers seem vague or unrelated to the questions. The patient also leans forward and frowns, listening intently to the nurse. What would be an appropriate question for the nurse to ask in this situation?
Answer Choices: 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. “You’re having trouble focusing on what I’m saying. What is distracting you?”
Answer: A
Question: At one point in an assessment interview a nurse asks, “Does your faith help you in stressful situations?” This question would be asked during the assessment of what focus?
Answer Choices: a. Culture b. Religious affiliation c. Educational background d. Coping strategies
Answer: D
Question: When a new patient is hospitalized, a nurse takes the patient on a unit tour, explains the rules of the unit, and discusses the daily schedule. The nurse is engaged in what aspect of care?
Answer Choices: a. Counseling b. Health teaching c. Milieu management d. Psychobiological intervention
Answer: C
Question: After formulating the nursing diagnoses for a new patient, what is the next action a nurse should take?
Answer Choices: 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: B
Question: 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.
Answer Choices: a. Deficient knowledge b. Ineffective coping c. Powerlessness d. Social isolation
Answer: D
Question: What does the Q and S relate to in the acronym QSEN?
Answer Choices: a. Qualitative Standardization b. Quality and Safety c. Quantitative Statements d. Quick Standards
Answer: B
Question: 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?
Answer Choices: a. Defensive coping b. Decisional conflict c. Risk for other-directed violence d. Impaired verbal communication
Answer: D
Question: Which action by the nurse is best associated with the demonstration of empathy?
Answer Choices: a. Observing the patient’s physical behavior and nonverbal communications b. Encouraging the patient time to express their concerns and physical needs c. Providing a therapeutic milieu where the patient is provided safety d. Encouraging the patient to communicate with their support system
Answer: A
Question: 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.)
Answer Choices: a. Uncooperative patient b. Patient’s subjective responses c. Only data obtained from the patient’s verbal responses d. Description of the patient’s behavior during the interview e. Analysis of why the patient is unresponsive during the interview
Answer: B, D
Question: Why is it important for a nurse to possess an appropriate degree of assertiveness? (Select all that apply.)
Answer Choices: a. Reduces interpersonal stress. b. Builds effective team relationships. c. Supports development of technical nursing skills. d. Reduces potential for the increased risk of client injury. e. Supports the delivery of effective, appropriate nursing care.
Answer: A, B, D, E