Nokea
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?
- 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
Rationale: When the patient (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 relatives or neighbors who are familiar with the patient.
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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
Rationale: Milieu management provides a therapeutic environment in which the patient can feel comfortable and safe while engaging in activities that meet the patient's physical and mental health needs.
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 without changes.
- 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
Rationale: Sleeping a total of 5 hours at night remains a reasonable outcome. The plan of care may be revised on the basis of the evaluation. Extending the time frame for attaining the outcome is appropriate. Examining interventions might result in planning an activity during the afternoon rather than permitting a nap.
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.
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.
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
Rationale: Nursing diagnoses are selected on the basis of the etiological factors and assessment findings or evidence. In this instance, the evidence shows social isolation that is caused by shyness and poorly developed social skills.