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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.
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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.
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.
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 patient's nursing diagnosis is Insomnia. The desired outcome is: 'Patient will sleep for a minimum of 5 hours nightly by October 31 .' On November 1, a review of the sleep data shows the patient sleeps an average of 4 hours nightly and takes a 2-hour afternoon nap. Which evaluation should be documented?
- A. Consistently demonstrated
- B. Often demonstrated
- C. Sometimes demonstrated
- D. Never demonstrated
Correct Answer: D
Rationale: Although the patient is sleeping 6 hours daily, the total is not in one uninterrupted session at night. Therefore, the outcome must be evaluated as never demonstrated.
Why is it important for a nurse to possess an appropriate degree of assertiveness?
- A. Reduces interpersonal stress.
- B. Builds effective team relationships.
- C. Supports development of technical nursing skills.
- D. Reduces potential for the increased risk of client injury.
- E. Supports the delivery of effective, appropriate nursing care.
Correct Answer: A,B,D,E
Rationale: Assertiveness is one of the most important skills for nurses in the workplace to reduce their interpersonal stress, build effective team relationships, and to provide sufficient nursing care. A nurse's ability to be assertive is key not only to preventing medical errors but also to reducing patients' risk and improving nursing care.