Nokea
Select the most appropriate label to complete this nursing diagnosis: related to feelings of shyness and poorly developed social skills as evidenced by watching television alone at home every evening.
- A. Deficient knowledge
- B. Ineffective coping
- C. Powerlessness
- D. Social isolation
Correct Answer: D
Rationale: Nursing diagnoses are selected on the basis of the etiological factors and assessment findings or evidence. In this instance, the evidence shows social isolation that is caused by shyness and poorly developed social skills.
You may also like to solve these questions
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.
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.
A newly admitted patient diagnosed with major depressive disorder has lost 20 pounds over the past month and has admitted having suicidal ideations. The patient has taken an antidepressant medication for 1 week without remission of symptoms. Select the priority nursing diagnosis.
- A. Imbalanced nutrition: Less than body requirements
- B. Chronic low self-esteem
- C. Risk for suicide
- D. Hopelessness
Correct Answer: C
Rationale: Risk for suicide is the priority diagnosis when the patient has both suicidal ideation and a plan to carry out the suicidal intent. Imbalanced nutrition, hopelessness, and chronic low self-esteem may be applicable nursing diagnoses, but these problems do not affect patient safety as urgently as a suicide attempt.
Which entry in the medical record best meets the requirement for problem-oriented charting?
- A. A: Pacing and muttering to self. P: Sensory perceptual alteration, related to internal auditory stimulation. I: Given fluphenazine 2.5 mg at 0900 and went to room to lie down. E: Calmer by 0930. Returned to lounge to watch TV.
- B. S: States, 'I feel like I'm ready to blow up.' O: Pacing hall, mumbling to self. A: Auditory hallucinations. P: Offer haloperidol 2 mg. I: haloperidol 2 mg at 0900 . E: Returned to lounge at 0930 and quietly watched TV.
- C. Agitated behavior. D: Patient muttering to self as though answering an unseen person. A: Given haloperidol 2 mg and went to room to lie down. E: Patient calmer. Returned to lounge to watch TV.
- D. Pacing hall and muttering to self as though answering an unseen person. haloperidol 2 mg administered at 0900 with calming effect in 30 minutes. Stated, 'I'm no longer bothered by the voices.'
Correct Answer: B
Rationale: Problem-oriented documentation uses the first letter of key words to organize data: S for subjective data, O for objective data, A for assessment, P for plan, I for intervention, and E for evaluation.
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.