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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.
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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.
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.
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 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.
Correct Answer: C
Rationale: 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.
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
Rationale: 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.
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
Rationale: The patient's 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.