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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.
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A patient begins a new program to assist with building social skills. In which part of the plan of care should a nurse record the item 'Encourage patient to attend one psychoeducational group daily'?
- A. Assessment
- B. Analysis
- C. Planning
- D. Implementation
- E. Evaluation
Correct Answer: D
Rationale: Interventions (implementation) are the nursing prescriptions to achieve the outcomes. None of the other options focus on this aspect of nursing care.
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.
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.
When a nurse assesses an older adult patient, the patient's answers seem vague or unrelated to the questions. The patient also leans forward and frowns, listening intently to the nurse. What would be an appropriate question for the nurse to ask in this situation?
- A. Are you having difficulty hearing when I speak?
- B. How can I make this assessment interview easier for you?
- C. I notice you are frowning. Are you feeling annoyed with me?
- D. You're having trouble focusing on what I'm saying. What is distracting you?
Correct Answer: A
Rationale: The patient's behaviors may indicate difficulty hearing. Identifying any physical need the patient may have at the onset of the interview and making accommodations are important considerations.
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.