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Which statement about targeted assessments is accurate?
- A. The need for a targeted assessment is based on the application of the nurse's knowledge of pathophysiology and the presenting symptoms.
- B. The need for a targeted assessment is based on the application of the nurse's knowledge of developmental needs and developmental delays.
- C. Targeted assessment is done on an annual basis for existing clients rather than a complete assessment that is done for new clients.
- D. Targeted assessments consist of a brief medical history and a complete assessment consists of a complete health history and a complete physical assessment.
Correct Answer: A
Rationale: Targeted assessments (A) focus on specific symptoms using pathophysiology.
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Which is an important nursing intervention when giving care to a patient withdrawing from a central nervous system (CNS) stimulant?
- A. Make physical contact by frequently touching the patient.
- B. Offer intellectual activities requiring concentration.
- C. Avoid manipulation by denying the patient’s requests.
- D. Observe for depression and suicidal ideation.
Correct Answer: D
Rationale: The correct answer is D because observing for depression and suicidal ideation is crucial when caring for a patient withdrawing from CNS stimulants. Depression and suicidal ideation are common withdrawal symptoms, so monitoring for these signs is essential for the patient's safety. It allows for early intervention and appropriate support to prevent any harm.
Choice A is incorrect as frequent physical contact may not be appropriate and can potentially agitate the patient during withdrawal. Choice B is incorrect as intellectual activities requiring concentration may overwhelm the patient who is already going through withdrawal symptoms. Choice C is incorrect as denying the patient's requests can lead to increased agitation and resistance during withdrawal, which is not conducive to effective care.
What is the most appropriate response when a patient's behavior or comments during an office visit trigger anger or negative emotions in the physician?
- A. Confront the patient immediately
- B. Recognize these emotions and maintain control
- C. Ignore the comments and send in a resident to see the patient
- D. End the visit and schedule a follow-up with another physician
Correct Answer: B
Rationale: Self-awareness and control preserve professionalism and care quality.
Select the standardized “hand off†change of shift reporting system that is accurately paired with its elements.
- A. SBAR: Symptoms, background, assessment and recommendations
- B. ISBAR: Interventions, symptoms, background, assessment and recommendations
- C. The Five Ps: The patient, plan, purpose, problems and precautions
- D. BATON: Background, assessment, timing, ownership and next plans
Correct Answer: B
Rationale: ISBAR includes these elements for structured communication.
The primary factor that makes an event a crisis is the:
- A. Type of loss that the event causes.
- B. Nature of the stress caused by the event.
- C. Ineffectiveness of one's usual coping strategies.
- D. Preexistence of a stress-related mental illness.
Correct Answer: C
Rationale: The correct answer is C because the primary factor that makes an event a crisis is the ineffectiveness of one's usual coping strategies. When an event overwhelms an individual's ability to cope with it using their usual strategies, it can lead to a crisis. Choice A is incorrect because the type of loss alone does not determine if an event is a crisis. Choice B is incorrect as the nature of stress is subjective and can vary among individuals. Choice D is incorrect because the preexistence of a stress-related mental illness is not necessarily a prerequisite for an event to be considered a crisis.
An adult has a history of physical violence against family when frustrated, followed by periods of remorse after each outburst. Which finding indicates a successful plan of care? The adult:
- A. expresses frustration verbally instead of physically.
- B. explains the rationale for behaviors to the victim.
- C. identifies three personal strengths.
- D. agrees to seek counseling.
Correct Answer: A
Rationale: The patient will have developed a healthier way of coping with frustration if it is expressed verbally instead of physically. The incorrect options do not confirm achievement of outcomes.