Nokea
Select the best outcome for a patient with this nursing diagnosis: impaired social interaction, related to sociocultural dissonance as evidenced by stating, 'Although I'd like to, I don't join in because I don't speak the language very well.' What should the focus of an appropriate outcome be?
- A. Demonstrating improved social skills
- B. Expressing a desire to interact with others
- C. Becoming more independent in decision making
- D. Selecting and participating in one group activity per day
Correct Answer: D
Rationale: The outcome describes social involvement on the part of the patient. Neither cooperation nor independence has been an issue. The patient has already expressed a desire to interact with others. Outcomes must be measurable.
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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.
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.
Which action by the nurse is best associated with the demonstration of empathy?
- A. Observing the patient's physical behavior and nonverbal communications
- B. Encouraging the patient time to express their concerns and physical needs
- C. Providing a therapeutic milieu where the patient is provided safety
- D. Encouraging the patient to communicate with their support system
Correct Answer: A
Rationale: Particularly in the area of psychiatric nursing, observation is not only important for clinical diagnosis, but it is also a first step in being empathetic. To be able to empathize, one must be able to recognize emotions, which inherently requires the skill of observation.
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.
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.