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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.
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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.
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.
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.
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 new staff nurse completes orientation to the psychiatric unit. This nurse will expect to ask an advanced practice nurse to perform which action for patients?
- A. Perform mental health assessment interviews.
- B. Establish therapeutic relationships.
- C. Prescribe psychotropic medication.
- D. Individualize nursing care plans.
Correct Answer: C
Rationale: Prescriptive privileges are granted to Master's-prepared nurse practitioners who have taken special courses on prescribing medications. The nurse prepared at the basic level performs mental health assessments, establishes relationships, and provides individualized care planning.