Nokea
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.
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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.
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.
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.
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.
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.