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A newly admitted patient diagnosed with major depressive disorder has lost 20 pounds over the past month and has admitted having suicidal ideations. 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
Correct Answer: C
Rationale: 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.
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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
Rationale: 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.
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?
- A. Culture
- B. Religious affiliation
- C. Educational background
- D. Coping strategies
Correct Answer: D
Rationale: 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 patient's faith helps deal with stress fits well here.
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
Rationale: 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 patient's chief symptom.
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?
- 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
Correct Answer: B,D
Rationale: Both the content and process of the interview should be documented. Providing only the patient's 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 patient's behavior is speculation, which is inappropriate.
What does 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
Rationale: 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.