Nokea
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.
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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.
When a new patient is hospitalized, a nurse takes the patient on a unit tour, explains the rules of the unit, and discusses the daily schedule. The nurse is engaged in what aspect of care?
- A. Counseling
- B. Health teaching
- C. Milieu management
- D. Psychobiological intervention
Correct Answer: C
Rationale: Milieu management provides a therapeutic environment in which the patient can feel comfortable and safe while engaging in activities that meet the patient's physical and mental health needs.
A patient states, 'I'm not worth anything. I have negative thoughts about myself. I feel anxious and shaky all the time. Sometimes I feel so sad that I want to go to sleep and never wake up.' Which nursing intervention should have the highest priority?
- A. Self-esteem-building activities
- B. Anxiety self-control measures
- C. Sleep enhancement activities
- D. Suicide prevention
Correct Answer: D
Rationale: The nurse should place priority on monitoring and reinforcing suicide self-restraint because it relates directly and immediately to patient safety. Patient safety is always a priority concern.
What information is conveyed by nursing diagnoses?
- A. Medical judgments about the disorder
- B. Goals and outcomes for the plan of care
- C. Unmet patient needs currently present
- D. Supporting data that validate the diagnoses
- E. Probable causes that will be targets for nursing interventions
Correct Answer: C,D,E
Rationale: Nursing diagnoses focus on phenomena of concern to nurses rather than on medical diagnoses. Goals and outcomes are part of the planning phase.
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.