One Questions With Detailed Solutions
Graded A+
Which statement is most accurate regarding the assessment of clients diagnosed with
psychiatric problems?
A. Medical history is of little significance and can be eliminated from the nursing
assessment.
B. Assessment provides a holistic view of the client, including biopsychosocial aspects.
C. Comprehensive assessments can be performed only by advanced practice nurses.
D. Psychosocial evaluations are gained by subjective reports rather than objective
observations. - CORRECT ANSWER-B - Assessment provides a holistic view of the
client
The assessment of clients diagnosed with psychiatric problems should provide a holistic
view of the client. A thorough assessment involves collecting and analyzing data from
the client, significant others, and health-care providers that may include the following
dimensions: physical, psychological, sociocultural, spiritual, cognitive, developmental,
economic, lifestyle, and functional abilities.
Which nursing diagnosis should a nurse identify as being correctly formulated?
A. Schizophrenia R/T biochemical alterations AEB altered thought
B. Self-care deficit: hygiene R/T altered thought as AEB disheveled appearance
C. Depressed mood R/T multiple life stressors
D. Developmental disability R/T early-onset schizophrenia AEB hallucinations -
CORRECT ANSWER-B - Self-care deficit: hygiene R/T altered thought as AEB
disheveled appearance
,The nurse should determine that the correctly written diagnosis would be Self-care
deficit: hygiene R/T altered thought AEB disheveled appearance. The nursing diagnosis
should describe the unhealthy response (inference), the contributing factors, and the
data that support the inference.
Which expected client outcome should a nurse identify as being correctly formulated?
A. Client will feel happier by discharge.
B. Client will demonstrate two relaxation techniques.
C. Client will verbalize triggers to anger by end of session.
D. Client will initiate interaction with one peer during free time within 2 days. -
CORRECT ANSWER-D - Client will initiate interaction with one peer during free time
within 2 days.
The statement Client will initiate interaction with one peer during free time within 2 days
is an example of a correctly formulated expected outcome. Outcomes should be
measurable, realistic, client-focused goals that include a time frame. Appropriate
nursing interventions are guided by client outcomes.
What is the purpose when a nurse gathers client information?
A. It enables the nurse to modify client behaviors related to personality disorders.
B. It enables the nurse to make sound clinical judgments and plan appropriate client
care.
C. It enables the nurse to prescribe the appropriate medications.
D. It enables the nurse to assign the appropriate Axis I diagnosis. - CORRECT
ANSWER-B- It enables the nurse to make sound clinical judgments and plan
appropriate client care.
The purpose of gathering client information is to enable the nurse to make sound clinical
nursing judgments and plan appropriate care. The nurse should complete a thorough
assessment of the client, including information collected from the client, significant
, others, and health-care providers (consistent with HIPAA laws and the clients right to
confidentiality).
The following outcome was developed for a client: Client will list five personal strengths
by the end of day 1. Which correctly written nursing diagnostic statement most likely
generated the development of this outcome?
A. Altered self-esteem R/T years of emotional abuse AEB self-deprecating statements
B. Self-care deficit R/T altered thought processes
C. Disturbed body image R/T major depressive disorder AEB mood rating of 2/10
D. Risk for disturbed self-concept R/T hopelessness AEB suicide attempt - CORRECT
ANSWER-A- Altered self-esteem R/T years of emotional abuse AEB self-deprecating
statements
The nurse should determine that altered self-esteem and self-deprecating statements
would generate the outcome to list personal strengths by the end of day 1. Self-care
deficit, disturbed body image, and risk for disturbed self-concept would generate
specific outcomes in accordance with specific needs and goals. The self-care deficit and
risk for disturbed self-concept nursing diagnoses are incorrectly written.
How should a nurse prioritize nursing diagnoses?
A. By the established goal of care
B. By the life-threatening potential
C. By the physicians priority of care
D. By the clients preference - CORRECT ANSWER-B- By the life-threatening potential
The nurse should prioritize nursing diagnoses related to life-threatening potential. Safety
is always the nurses first priority.