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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.
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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.
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.
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.
Nursing behaviors associated with the implementation phase of the nursing process are concerned with the responsibilities of the psychiatric mental health nurse?
- A. Participating in the mutual identification of patient outcomes
- B. Gathering accurate and sufficient patient-centered data
- C. Comparing patient responses and expected outcomes
- D. Carrying out interventions and coordinating care
Correct Answer: D
Rationale: Nursing behaviors relating to implementation include using available resources, performing interventions, finding alternatives when necessary, and coordinating care with other team members.
A nurse works with a patient to establish outcomes. The nurse believes that one outcome suggested by the patient is not in the patient's best interest. What is the nurse's best action?
- A. Remain silent.
- B. Educate the patient that the outcome is not realistic.
- C. Explore with the patient possible consequences of the outcome.
- D. Formulate a more appropriate outcome without the patient's input.
Correct Answer: C
Rationale: The nurse should not impose outcomes on the patient; however, the nurse has a responsibility to help the patient evaluate what is in his or her best interest. Exploring possible consequences is an acceptable approach.