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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.
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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.
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
Rationale: Interventions (implementation) are the nursing prescriptions to achieve the outcomes. None of the other options focus on this aspect of nursing care.
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.
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
Rationale: The third step of the nursing process is planning and outcome identification. Outcomes cannot be determined until the nursing assessment is complete and the nursing diagnoses have been formulated.
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. Affect and mood
- D. Perceptual disturbances
Correct Answer: B
Rationale: Assessing cognition involves determining a patient's judgment and decision-making capabilities. In this case, the nurse expects a response of 'Call my doctor' if the patient's cognition and judgment are intact.