Nokea
A nurse is preparing to administer an as-needed (PRN) medication. Which of the following would the nurse need to keep in mind when documenting administration?
- A. It requires a separate entry that includes reason for administration, dosage, route, and response to the medication the first time it is administered to a patient.
- B. It requires a separate entry that includes reason for administration, dosage, route, and response to the medication every time it is administered to a patient.
- C. It requires a separate entry that includes reason for administration, dosage, and route the first time it is administered to a patient.
- D. It requires a separate entry that includes reason for administration, dosage, and route every time it is administered to a patient.
Correct Answer: B
Rationale: The correct answer is B because when documenting administration of PRN medication, the nurse must include the reason for administration, dosage, route, and response every time it is given. This ensures comprehensive documentation for monitoring the patient's response to the medication and helps in evaluating the effectiveness of the treatment. Option A is incorrect because documenting the response is necessary each time, not just the first time. Option C is incorrect as it does not include documenting the response, which is crucial for assessing the medication's effectiveness. Option D is also incorrect as it excludes documenting the response, which is essential for evaluating the patient's progress.
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A nursing instructor has prepared a lecture about the scope and standards of practice of psychiatric nurses. The instructor determines that the teaching was effective when the students identify which of the following as common to both basic and advanced level practice?
- A. Case management
- B. Program development
- C. Clinical supervision
- D. Community interventions
Correct Answer: A
Rationale: The correct answer is A: Case management. This is common to both basic and advanced level practice for psychiatric nurses because it involves coordinating care, advocating for patients, and ensuring continuity of services. Basic level nurses may handle simpler cases, while advanced level nurses may manage more complex cases.
Choice B: Program development may be more common in advanced practice where nurses may be involved in creating new programs or services.
Choice C: Clinical supervision is typically a responsibility of advanced practice nurses who oversee and guide other staff members.
Choice D: Community interventions may also be more common in advanced practice where nurses may lead community-based initiatives.
A nurse is demonstrating behaviors that the treatment team is attempting to get the patient to develop. The nurse is integrating which theory?
- A. Erikson’s model of psychosocial development
- B. Albert Bandura’s social cognitive theory
- C. Skinner’s operant conditioning
- D. Freud’s psychoanalytic model
Correct Answer: B
Rationale: The correct answer is B: Albert Bandura's social cognitive theory. The nurse is integrating this theory by demonstrating behaviors for the patient to develop through observational learning and modeling. Bandura's theory emphasizes that individuals learn by observing others and imitating their behaviors. The treatment team is likely using this approach to encourage the patient to adopt positive behaviors by showcasing them through the nurse's actions.
Incorrect Choices:
A: Erikson’s model of psychosocial development - This theory focuses on stages of psychosocial development and identity formation, not on observational learning or modeling.
C: Skinner’s operant conditioning - This theory revolves around reinforcement and punishment to shape behavior, which is different from the observational learning emphasized in the scenario.
D: Freud’s psychoanalytic model - This theory is based on unconscious processes and early childhood experiences, not on observational learning and modeling as seen in the nurse's behavior.
A psychiatric-mental health nurse determines that a patient is competent when he is able to do which of the following?
- A. Speak coherent English.
- B. Communicate his or her choices.
- C. Write a `living will.
- D. Comply with the medical regimen.
Correct Answer: B
Rationale: The correct answer is B because competency involves the ability to communicate one's choices. Competency is determined by the patient's capacity to understand information, make reasoned decisions, and communicate preferences. This enables the patient to actively participate in their healthcare decisions. Choices A, C, and D are incorrect because speaking coherent English, writing a living will, and complying with a medical regimen do not solely demonstrate competency in decision-making and communication of choices. These actions may be important but do not encompass the full scope of competency in the context of psychiatric-mental health nursing.
A psychiatric-mental health nurse is providing care for a patient with a mental disorder. The patient is participating in the decision-making process. The nurse interprets this as which component of recovery?
- A. Self-direction
- B. Empowerment
- C. Person-centered
- D. Holistic
Correct Answer: A
Rationale: The correct answer is A: Self-direction. In the context of recovery, self-direction refers to the patient's ability to actively participate in decisions regarding their care and treatment. By involving the patient in the decision-making process, the nurse is promoting the patient's autonomy and self-determination, which are key components of recovery in mental health. This approach empowers the patient to take control of their own recovery journey and promotes a sense of ownership over their treatment plan.
Summary of other choices:
B: Empowerment - While empowerment is related to self-direction, it focuses more on giving the patient the tools and resources to make informed decisions rather than actively involving them in the decision-making process.
C: Person-centered - This choice emphasizes tailoring care to the individual's unique needs and preferences, which is important in recovery but not specifically related to the patient's active participation in decision-making.
D: Holistic - This choice pertains to considering all aspects of the patient's well-being, including physical,
A psychiatric-mental health nurse is documenting information in a patient’s medical record. Which of the following would be least likely to increase the nurse’s legal liability?
- A. `Patient reported that he was feeling better today than yesterday.
- B. `Administered haloperidol 10 mg IM stat as ordered for agitation.
- C. `Patient was talking with another staff member and started screaming.
- D. `Applied restraints to all four patient extremities.
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. Patient's self-report of feeling better is subjective and reflects the patient's perception, not the nurse's actions or decisions.
2. This documentation does not involve any direct intervention or action by the nurse, hence reducing legal liability.
3. It reflects positive progress in the patient's condition, which is generally a favorable indicator in psychiatric care.
4. It does not raise concerns about potential adverse outcomes or deviations from standard practice.
Summary:
- Choice A is least likely to increase legal liability as it is a subjective report by the patient.
- Choices B, C, and D involve direct actions or interventions by the nurse that could have legal implications and potential risks to patient safety.