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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.
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What does the Q and S relate to in the acronym QSEN?
- A. Qualitative Standardization
- B. Quality and Safety
- C. Quantitative Statements
- D. Quick Standards
Correct Answer: B
Rationale: QSEN represents national initiatives centered on patient safety and quality. The primary goal of QSEN is to prepare future nurses with the knowledge, skills, and attitudes to increase the quality, care, and safety in the health care setting in which they work.
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.
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 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.
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.