Nokea
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.
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Nursing behaviors associated with the implementation phase of the nursing process are concerned with the responsibilities of the psychiatric mental health nurse?
- A. Participating in the mutual identification of patient outcomes
- B. Gathering accurate and sufficient patient-centered data
- C. Comparing patient responses and expected outcomes
- D. Carrying out interventions and coordinating care
Correct Answer: D
Rationale: Nursing behaviors relating to implementation include using available resources, performing interventions, finding alternatives when necessary, and coordinating care with other team members.
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.
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.
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.
Which statement made by a patient during an initial assessment interview should serve as the priority focus for the plan of care?
- A. I can always trust my family.
- B. It seems like I always have bad luck.
- C. You never know who will turn against you.
- D. I hear evil voices that tell me to do bad things.
Correct Answer: D
Rationale: The statement regarding evil voices tells the nurse that the patient is experiencing auditory hallucinations. The other statements are vague and do not clearly identify the patient's chief symptom.