Nokea
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. Which evaluation should be documented?
- A. Consistently demonstrated
- B. Often demonstrated
- C. Sometimes demonstrated
- D. Never demonstrated
Correct Answer: D
Rationale: Although the patient is sleeping 6 hours daily, the total is not in one uninterrupted session at night. Therefore, the outcome must be evaluated as never demonstrated.
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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.
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.
Before assessing a new patient, a nurse is told by another health care worker, 'I know that patient. No matter how hard we work, there isn't much improvement by the time of discharge.' What action will the nurse take to provide appropriate care for this patient?
- A. Document the other worker's assessment of the patient.
- B. Assess the patient based on data collected from all sources.
- C. Validate the worker's impression by contacting the patient's significant other.
- D. Discuss the worker's impression with the patient during the assessment interview.
Correct Answer: B
Rationale: Assessment should include data obtained from both the primary and reliable secondary sources. Biased assessments by others should be evaluated as objectively as possible by the nurse, keeping in mind the possible effects of countertransference.
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.
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.