375 MILESTONE 4 PRACTICE QUESTIONS AND
DETAILED SOLUTIONS
◉ Question 2 of 3
A patient with a history of an anxiety disorder is brought to the
emergency department by their spouse, who tells the nurse the
patient is having a panic attack. Which strategy can the nurse use to
make collecting the patient history data more tolerable for the
patient?
Review the record for a history of similar episodes in the past.
Stop asking questions of the patient until they have calmed down.
Repeat the questions until the patient is able to provide a response.
Avoid asking questions of the patient and gather assessment data
from the spouse..
Answer: Review the record for a history of similar episodes in the
past.
Knowing the patient's history, including previous episodes and
treatment, allows the nurse to ask only critical questions and not
exhaust the patient with questions that the nurse can find the
answers to in the medical record.
◉ Question 3 of 3
,Which explanation would the nursing instructor provide to students
regarding why the six-step nursing process approach is used in
mental health nursing?
The process is ingrained in nursing history and is important to
maintain.
Following this process is mandatory according to the state nurse
practice act (NPA).
The nurse is able to make judgements and choose behaviors relevant
to individual patient care.
The six steps allow the nurse to better understand the patient's
medical or mental health diagnosis..
Answer: The nurse is able to make judgements and choose
behaviors relevant to individual patient care.
Use of the six steps of the nursing process allows the nurse to
identify individual patient problems and select appropriate patient
goals and the interventions necessary to achieve those goals.
Following evaluation of the progress toward, or achievement of, the
outcomes and goals, the process starts again and remains ongoing.
This logical framework allows the nurse to make judgements and
revisions to the patient's plan of care.
◉ Question 1 of 3
Which aspects of Ms. Small's plan of care would the nurse document
as implementation?
Select all that apply.
, New onset depression
Avoid further weight loss
Sleep at least 6 hours each night
Take 20 mg of fluoxetine every morning
Decrease caffeinated beverages to no more than four per day.
Answer: Take 20 mg of fluoxetine every morning
Taking fluoxetine, a selective serotonin reuptake inhibitor
antidepressant, would be documented as implementation. This is an
action Ms. Small will take to attempt to reach an identified outcome
(returning to at least one pleasurable activity).
Decrease caffeinated beverages to no more than four per day
Decreasing caffeine intake would be documented as
implementation. This is an action that Ms. Small will take to attempt
to reach an identified outcome (improved nightly sleep).
◉ Question 2 of 3
Which aspect of the patient outcome "Mr. X will report his pain at a 2
or below on a 0-10 pain scale" is missing?
A reliable measuring tool
A description of what is being measured
A time by which the outcome will be achieved
An indication of what will change for the patient.
Answer: A time by which the outcome will be achieved
DETAILED SOLUTIONS
◉ Question 2 of 3
A patient with a history of an anxiety disorder is brought to the
emergency department by their spouse, who tells the nurse the
patient is having a panic attack. Which strategy can the nurse use to
make collecting the patient history data more tolerable for the
patient?
Review the record for a history of similar episodes in the past.
Stop asking questions of the patient until they have calmed down.
Repeat the questions until the patient is able to provide a response.
Avoid asking questions of the patient and gather assessment data
from the spouse..
Answer: Review the record for a history of similar episodes in the
past.
Knowing the patient's history, including previous episodes and
treatment, allows the nurse to ask only critical questions and not
exhaust the patient with questions that the nurse can find the
answers to in the medical record.
◉ Question 3 of 3
,Which explanation would the nursing instructor provide to students
regarding why the six-step nursing process approach is used in
mental health nursing?
The process is ingrained in nursing history and is important to
maintain.
Following this process is mandatory according to the state nurse
practice act (NPA).
The nurse is able to make judgements and choose behaviors relevant
to individual patient care.
The six steps allow the nurse to better understand the patient's
medical or mental health diagnosis..
Answer: The nurse is able to make judgements and choose
behaviors relevant to individual patient care.
Use of the six steps of the nursing process allows the nurse to
identify individual patient problems and select appropriate patient
goals and the interventions necessary to achieve those goals.
Following evaluation of the progress toward, or achievement of, the
outcomes and goals, the process starts again and remains ongoing.
This logical framework allows the nurse to make judgements and
revisions to the patient's plan of care.
◉ Question 1 of 3
Which aspects of Ms. Small's plan of care would the nurse document
as implementation?
Select all that apply.
, New onset depression
Avoid further weight loss
Sleep at least 6 hours each night
Take 20 mg of fluoxetine every morning
Decrease caffeinated beverages to no more than four per day.
Answer: Take 20 mg of fluoxetine every morning
Taking fluoxetine, a selective serotonin reuptake inhibitor
antidepressant, would be documented as implementation. This is an
action Ms. Small will take to attempt to reach an identified outcome
(returning to at least one pleasurable activity).
Decrease caffeinated beverages to no more than four per day
Decreasing caffeine intake would be documented as
implementation. This is an action that Ms. Small will take to attempt
to reach an identified outcome (improved nightly sleep).
◉ Question 2 of 3
Which aspect of the patient outcome "Mr. X will report his pain at a 2
or below on a 0-10 pain scale" is missing?
A reliable measuring tool
A description of what is being measured
A time by which the outcome will be achieved
An indication of what will change for the patient.
Answer: A time by which the outcome will be achieved
