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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
Rationale: Patient interpretation of proverbial statements gives assessment information regarding the patient's ability to abstract, which is an aspect of cognition.
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A patient diagnosed with major depressive disorder has lost 20 pounds in 1 month. The patient has chronic low self-esteem and a plan for suicide. The patient has taken an antidepressant medication for 1 week. Which nursing intervention is most directly related to this priority: 'Patient will refrain from gestures and attempts to harm self'?
- A. Implement suicide prevention interventions.
- B. Frequently offer high-calorie snacks and fluids.
- C. Assist the patient to identify three personal strengths.
- D. Observe patient for therapeutic effects of antidepressant medication.
Correct Answer: A
Rationale: Implementing suicide precautions is the only option related to patient safety. The other options, related to nutrition, self-esteem, and medication therapy, are important but are not priorities.
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.
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
Rationale: The nurse should place priority on monitoring and reinforcing suicide self-restraint because it relates directly and immediately to patient safety. Patient safety is always a priority concern.
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
Rationale: The defining characteristics are more related to the nursing diagnosis of impaired verbal communication than to the other nursing diagnoses.
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.