Question: A patient’s 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 patient’s 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 Correct Answer D
Question: A patient’s 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 nurse’s next action? a. Continue the current plan
A patient’s 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 nurse’s next action? a. Continue the current plan 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 Correct Answer D
Question: 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
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 Correct Answer D
Question: 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 isn’t much improvement by the time of discharge.” What action will the nurse take to provide appropriate care for this patient? a. Document the other worker’s assessment of the patient.
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 isn’t much improvement by the time of discharge.” What action will the nurse take to provide appropriate care for this patient? a. Document the other worker’s assessment of the patient. b. Assess the patient based on data collected from all sources. c. Validate the worker’s impression by contacting the patient’s significant other. d. Discuss the worker’s impression with the patient during the assessment interview. Correct Answer B
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? a. Self-esteem–building activities b. Anxiety self-control measures
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? a. Self-esteem–building activities b. Anxiety self-control measures c. Sleep enhancement activities d. Suicide prevention Correct 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? a. Demonstrating improved social skills
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? 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 Correct 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? 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.”
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.” Correct Answer D
Question: 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 2.5 mg at 0900 and went to room to lie down. E: Calmer by 0930. Returned to lounge to watch TV.”
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 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.’” Correct Answer B
Question: A patient admitted to the psychiatric unit following a suicide attempt is confused and unable to answer questions. What is the nurse’s best action to provide effective nursing care? 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.
A patient admitted to the psychiatric unit following a suicide attempt is confused and unable to answer questions. What is the nurse’s best action to provide effective nursing care? 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. Correct 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? a. Behavior b. Cognition c. Planning d. Implementation
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. Planning d. Implementation Correct Answer C
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? a. “That is not true. What you tell us is private and held in strict confidence. Your parents have no right to know.”
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? 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 ideation, 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.” Correct 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? a. Mood b. Attention c. Orientation d. Abstraction
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? a. Mood b. Attention c. Orientation d. Abstraction Correct Answer D
Question: When a nurse assesses an older adult patient, 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? a. “Are you having difficulty hearing when I speak?”
When a nurse assesses an older adult patient, 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? 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?” Correct 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 topics? a. Culture b. Religious affiliation c. Educational background d. Coping strategies
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 topics? a. Culture b. Religious affiliation c. Educational background d. Coping strategies Correct 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? a. Counseling b. Health teaching c. Milieu management d. Psychobiological intervention
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? a. Counseling b. Health teaching c. Milieu management d. Psychobiological intervention Correct Answer C
Question: 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.
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. Correct 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. a. Deficient knowledge b. Ineffective coping c. Powerlessness d. Social isolation
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 Correct Answer D
Question: What do the Q and S relate to in the acronym QSEN? a. Qualitative Standardization b. Quality and Safety c. Quantitative Statements d. Quick Standards
What do the Q and S relate to in the acronym QSEN? a. Qualitative Standardization b. Quality and Safety c. Quantitative Statements d. Quick Standards Correct 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? a. Defensive coping b. Decisional conflict c. Risk for other-directed violence
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 Correct Answer D