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NCLEX: Psychiatric Nursing Complete test bank

Chapter 1: Practicing the Science and Art of Psychiatric Nursing Test Bank MULTIPLE CHOICE 1. Which outcome, focused on recovery, would be expected in the plan of care for a patient living in the community with serious and persistent mental illness? Within 3 months, the patient will: a. deny suicidal ideation. b. report a sense of well-being. c. take medications as prescribed. d. attend clinic appointments on time. ANS: B Recovery emphasizes managing symptoms, reducing psychosocial disability, and improving role performance. The goal of recovery is to empower the individual with mental illness to achieve a sense of meaning and satisfaction in life and to function at the highest possible level of wellness. The incorrect options focus on the classic medical model rather than recovery. DIF: Cognitive Level: Application REF: Pages: 2-3 TOP: Nursing Process: Outcomes Identification MSC: NCLEX: Health Promotion and Maintenance 2. A patient is hospitalized for depression and suicidal ideation after their spouse asks for a divorce. Select the nurse’s most caring comment. a. “Let’s discuss some means of coping other than suicide when you have these feelings.” b. “I understand why you’re so depressed. When I got divorced, I was devastated too.” c. “You should forget about your marriage and move on with your life.” d. “How did you get so depressed that hospitalization was necessary?” ANS: A The nurse’s communication should evidence caring and a commitment to work with the patient. This commitment lets the patient know the nurse will help. Probing and advice are not helpful or therapeutic interventions. DIF: Cognitive Level: Application REF: Pages: 6-8 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 3. In the shift-change report, an off-going nurse criticizes a patient who wears heavy makeup. Which comment by the nurse who receives the report bestdemonstrates advocacy? a. “This is a psychiatric hospital. Craziness is what we are all about.” b. “Let’s all show acceptance of this patient by wearing lots of makeup too.” c. “Your comments are inconsiderate and inappropriate. Keep the report objective.” d. “Our patients need our help to learn behaviors that will help them get along in society.” ANS: D Accepting patients’ needs for self-expression and seeking to teach skills that will contribute to their well-being demonstrate respect and are important parts of advocacy. The on-coming nurse needs to take action to ensure that others are not prejudiced against the patient. Humor can be appropriate within the privacy of a shift report but not at the expense of respect for patients. Judging the off-going nurse in a critical way will create conflict. Nurses must show compassion for each other. DIF: Cognitive Level: Application REF: Page: 8 TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment 4. A nurse assesses a newly admitted patient with depression. Which statement is an example of “attending”? a. “We all have stress in life. Being in a psychiatric hospital isn’t the end of the world.” b. “Tell me why you felt you had to be hospitalized to receive treatment for your depression.” c. “You will feel better after we get some antidepressant medication started for you.” d. “I’d like to sit with you a while so you may feel more comfortable talking with me.” ANS: D Attending is a technique that demonstrates the nurse’s commitment to the relationship and reduces feelings of isolation. This technique shows respect for the patient and demonstrates caring. Generalizations, probing, and false reassurances are nontherapeutic. DIF: Cognitive Level: Application REF: Page: 8 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 5. A patient shows the nurse an article from the Internet about a healthproblem. Which characteristic of the web site’s address most alerts the nurse that the site may have biased and prejudiced information? a. Address ends in “.org.” b. Address ends in “.com.” c. Address ends in “.gov.” d. Address ends in “.net.” ANS: B Financial influences on a site are a clue that the information may be biased. “.com” at the end of the address indicates that the site is a commercial one. “.gov” indicates that the site is maintained by a government entity. “.org” indicates that the site is nonproprietary; the site may or may not have reliable information, but it does not profit from its activities. “.net” can have multiple meanings. DIF: Cognitive Level: Comprehension REF: Page: 5 TOP: Nursing Process: Evaluation MSC: NCLEX: Health Promotion and Maintenance 6. A nurse says, “When I was in school I learned to call upset patients by name to get their attention, but I read a descriptive research study that says that this approach doesn’t work. I’m going stop calling patients by name.” Which statement is the best appraisal of this nurse’s comment? a. One descriptive research study rarely provides enough evidence to change practice. b. Staff nurses apply new research findings only with the help from clinical nurse specialists. c. New research findings should be incorporated into clinical algorithms before using them in practice. d. The nurse misinterpreted the results of the study. Classic tenets of practice do not change. ANS: A Descriptive research findings provide evidence for practice but must be viewed in relation to other studies before practice changes. One study is not enough. Descriptive studies are low on the hierarchy of evidence. Clinical algorithms use flow charts to manage problems and do not specify one response to a clinical problem. Classic tenets of practice should change as research findings provide evidence for change. DIF: Cognitive Level: Analysis REF: Pages: 3-4 TOP: Nursing Process: Evaluation MSC: NCLEX: Health Promotion and Maintenance 7. Two nursing students discuss career plans after graduation. One studentwants to enter psychiatric nursing. The other student asks, “Why would you want to be a psychiatric nurse? All they do is talk. You’ll lose your skills.” Select the best response by the student interested in psychiatric nursing. a. “Psychiatric nurses practice in safer environments than other specialties. Nurse-to-patient ratios must be better because of the nature of patients’ problems.” b. “Psychiatric nurses use complex communication skills, as well as critical thinking, to solve multidimensional problems. I’m challenged by those situations.” c. “I think I’ll be good in the mental health field. I do not like clinical rotations in school, so I don’t want to continue them after I graduate.” d. “Psychiatric nurses don’t have to deal with as much pain and suffering as medical surgical nurses. That appeals to me.” ANS: B The practice of psychiatric nursing requires a different set of skills than medical surgical nursing, although substantial overlap does exist. Psychiatric nurses must be able to help patients with medical and mental health problems, reflecting the holistic perspective these nurses must have. Nurse-patient ratios and workloads in psychiatric settings have increased, similar to other specialties. Psychiatric nursing involves clinical practice, not simply documentation. Psychosocial pain is real and can cause as much suffering as physical pain. DIF: Cognitive Level: Application REF: Page: 3 TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment 8. Which research evidence would most influence a group of nurses to change their practice? a. Expert committee report of recommendations for practice b. Systematic review of randomized controlled trials c. Nonexperimental descriptive study d. Critical pathway ANS: B Research findings are graded using a hierarchy of evidence. A systematic review of randomized controlled trials is Level A and provides the strongest evidence for changingpractice. Expert committee recommendations and descriptive studies lend less powerful and influential evidence. A critical pathway is not evidence; it incorporates research findings after they have been analyzed. DIF: Cognitive Level: Application REF: Pages: 4-6 TOP: Nursing Process: Analysis MSC: NCLEX: Safe, Effective Care Environment 9. A bill introduced in Congress would reduce funding for the care of people with mental illnesses. A group of nurses write letters to their elected representatives in opposition to the legislation. Which role have the nurses fulfilled? a. Advocacy b. Attending c. Recovery d. Evidence-based practice ANS: A An advocate defends or asserts another’s cause, particularly when the other person lacks the ability to do that for him- or herself. Examples of individual advocacy include helping patients understand their rights or make decisions. On a community scale, advocacy includes political activity, public speaking, and publication in the interest of improving the individuals with mental illness; the letter-writing campaign advocates for that cause on behalf of patients who are unable to articulate their own needs. DIF: Cognitive Level: Comprehension REF: Page: 8 TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment 10. An informal group of patients discuss their perceptions of nursing care. Which comment best indicates a patient’s perception that his or her nurse is caring? a. “My nurse always asks me which type of juice I want to help me swallow my medication.” b. “My nurse explained my treatment plan to me and asked for my ideas about how to make it better.” c. “My nurse told me that if I take all the medicines the doctor prescribes I will get discharged soon.” d. “My nurse spends time listening to me talk about my problems. That helps me feel like I’m not alone.” ANS: D Caring evidences empathic understanding, as well as competency. It helps change pain and suffering into a shared experience, creating a human connection that alleviates feelings of isolation. The remaining options give examples of statements that demonstrateadvocacy or giving advice. DIF: Cognitive Level: Application REF: Pages: 3-4|Page: 8 TOP: Nursing Process: Evaluation MSC: NCLEX: Psychosocial Integrity 11. A patient who immigrated to the United States from Honduras was diagnosed with schizophrenia. The patient took an antipsychotic medication for 3 weeks but showed no improvement. Which resource should the treatment team consult for information on more effective medications for this patient? a. Clinical algorithm b. Clinical pathway c. Clinical practice guideline d. International Statistical Classification of Diseases and Related Health Problems (ICD) ANS: A A clinical algorithm is a guideline that describes diagnostic and/or treatment approaches drawn from large databases of information. These guidelines help the treatment team make decisions cognizant of an individual patient’s needs, such as ethnic origin, age, or gender. A clinical pathway is a map of interventions and treatments related to a specific disorder. Clinical practice guidelines summarize best practices about specific health problems. The ICD classifies diseases. DIF: Cognitive Level: Application REF: Page: 6 TOP: Nursing Process: Evaluation MSC: NCLEX: Safe, Effective Care Environment 12. Which historical nursing leader helped focus practice to recognize the importance of science in psychiatric nursing? a. Abraham Maslow b. Hildegard Peplau c. Kris Martinsen d. Harriet Bailey ANS: B Although all these leaders included science as an important component of practice, Hildegard Peplau most influenced its development in psychiatric nursing. Maslow was not a nurse, but his theories influence how nurses prioritize problems and care. Bailey wrote a textbook in the 1930s on psychiatric nursing interventions. Kris Martinsen emphasized the importance of caring in nursing practice. DIF: Cognitive Level: Knowledge REF: Page: 4 TOP: Nursing Process: N/A MSC: NCLEX: Psychosocial Integrity 13. A nurse consistently strives to demonstrate caring behaviors during interactions with patients. Which reaction by a patient indicates this nurse is effective? Apatient reports feeling: a. distrustful l of others. b. connected with others. c. uneasy about the future. d. discouraged with efforts to improve. ANS: B A patient is likely to respond to caring with a sense of connectedness with others. The absence of caring can make patients feel distrustful, disconnected, uneasy, and discouraged. DIF: Cognitive Level: Comprehension REF: Pages: 7-8 TOP: Nursing Process: Evaluation MSC: NCLEX: Psychosocial Integrity MULTIPLE RESPONSE 1. An experienced nurse says to a new graduate, “When you’ve practiced as long as I have, you’ll instantly know how to take care of psychotic patients.” What is the new graduate’s best analysis of this comment? Select all that apply. a. The experienced nurse may have lost sight of patients’ individuality, which may compromise the integrity of practice. b. New research findings must be continually integrated into a nurse’s practice to provide the most effective care. c. Experience provides mental health nurses with the tools and skills needed for effective professional practice. d. Experienced psychiatric nurses have learned the best ways to care for psychotic patients through trial and error. e. Effective psychiatric nurses should be continually guided by an intuitive sense of patients’ needs. ANS: A, B Evidence-based practice involves using research findings to provide the most effective nursing care. Evidence is continually emerging; therefore, nurses cannot rely solely on experience. The effective nurse also maintains respect for each patient as an individual. Overgeneralization compromises that perspective. Intuition and trial and error are unsystematic approaches to care. DIF: Cognitive Level: Application REF: Pages: 2-3|Page: 6 TOP: Nursing Process: Analysis MSC: NCLEX: Safe, Effective Care Environment2. Which patient statements identify qualities of nursing practice with high therapeutic value? (Select all that apply.) “The nurse: a. talks in language I can understand.” b. helps me keep track of my medications.” c. is willing to go to social activities with me.” d. lets me do whatever I choose without interfering.” e. looks at me as a whole person with different needs.” ANS: A, B, E Each correct answer demonstrates caring is an example of appropriate nursing foci: communicating at a level understandable to the patient, using holistic principles to guide care, and providing medication supervision. The incorrect options suggest a laissez-faire attitude on the part of the nurse, when the nurse should instead provide thoughtful feedback and help patients test alternative solutions or violate boundaries. DIF: Cognitive Level: Application REF: Pages: 6-8 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial IntegrityChapter 6: Legal and Ethical Basis for Practice Test Bank MULTIPLE CHOICE 1. A psychiatric nurse best implements the ethical principle of autonomy when he or she: a. intervenes when a self-mutilating patient attempts to harm self. b. stays with a patient who is demonstrating a high level of anxiety. c. suggests that two patients who are fighting be restricted to the unit. d. explores alternative solutions with a patient, who then makes a choice. ANS: D Autonomy is the right to self-determination, that is, to make one’s own decisions. When the nurse explores alternatives with the patient, the patient is better equipped to make an informed, autonomous decision. Staying with a highly anxious patient or intervening with a self-mutilating patient demonstrates beneficence and fidelity. Suggesting that two fighting patients be restricted to the unit demonstrates the principles of fidelity and justice. DIF: Cognitive Level: Application REF: Page: 81|Page: 84 TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment 2. Which action by a psychiatric nurse best supports patients’ rights to be treated with dignity and respect? a. Consistently addressing each patient by title and surname. b. Strongly encouraging a patient to participate in the unit milieu. c. Discussing a patient’s condition with another health care provider in the elevator. d. Informing a treatment team that a patient is too drowsy to participate in care planning. ANS: A A simple way of showing respect is to address the patient by title and surname rather than assuming that the patient would wish to be called by his or her first name. Discussing a patient’s condition with a health care provider in the elevator violates confidentiality. Informing a treatment team that the patient is too drowsy to participate in care planning violates patient autonomy. Encouraging a patient to participate in the unit milieu exemplifies beneficence and fidelity.DIF: Cognitive Level: Application REF: Page: 86 TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment 3. Two hospitalized patients fight when they are in the same room. During a team meeting, a nurse asserts that safety is of paramount importance and therefore the treatment plans should call for both patients to be secluded to prevent them from injuring each other. This assertion: a. reveals that the nurse values the principle of justice. b. reinforces the autonomy of the two patients. c. violates the civil rights of the two patients. d. represents the intentional tort of battery. ANS: C Patients have a right to treatment in the least restrictive setting. Less restrictive measures should be tried first. Unnecessary seclusion may result in a charge of false imprisonment. Seclusion removes the patient’s autonomy. The principle by which the nurse is motivated is beneficence, not justice. The tort represented is false imprisonment, not battery. DIF: Cognitive Level: Application REF: Pages: 82-83|Page: 85 TOP: Nursing Process: Planning MSC: NCLEX: Safe, Effective Care Environment 4. In a team meeting a nurse says, “I’m concerned whether we are behaving ethically by using restraint to prevent one patient from self-mutilation while the care plan for another patient who has also self-mutilated calls for one-on-one supervision.” Which ethical principle most clearly applies to this situation? a. Beneficence b. Autonomy c. Fidelity d. Justice ANS: D The nurse is concerned about justice, that is, the fair treatment with the least restrictive methods for both patients. Beneficence means promoting the good of others. Autonomy is the right to make one’s own decisions. Fidelity is the observance of loyalty and commitment to the patient. DIF: Cognitive Level: Application REF: Page: 81 TOP: Nursing Process: Planning MSC: NCLEX: Safe, Effective Care Environment 5. Which scenario is an example of a tort? a. The primary nurse does not complete the plan of care for a patient within 24 hours of the patient’s admission. b. An advanced practice nurse recommends that a patient who is dangerous to self and others be voluntarily hospitalized. c. A patient’s admission status is changed from involuntary to voluntary after the patient’s hallucinations subside. d nurse gives an as-needed dose of ana. The primary nurse does not complete the plan of care for a patient within 24 hours of the patient’s admission. b. An advanced practice nurse recommends that a patient who is dangerous to self and others be voluntarily hospitalized. c. A patient’s admission status is changed from involuntary to voluntary after the patient’s hallucinations subside. d. A nurse gives an as-needed dose of an antipsychotic drug to a patient to prevent violent acting-out because a unit is short staffed. ANS: D A tort is a civil wrong against a person that violates his or her rights. Giving unnecessary medication for the convenience of staff members controls behavior in a manner similar to secluding a patient; thus false imprisonment is a possible charge. The other options do not exemplify torts. DIF: Cognitive Level: Application REF: Pages: 88-89 TOP: Nursing Process: Evaluation MSC: NCLEX: Safe, Effective Care Environment 6. A nurse’s neighbor asks, “Why aren’t people with mental illness kept in state institutions anymore?” What is the nurse’s best response? a. “Many people are still in psychiatric institutions. Inpatient care is needed because many people who are mentally ill are violent.” b. “Less restrictive settings are now available to care for individuals with mental illness.” c. “Our nation has fewer persons with mental illness; therefore fewer hospital beds are needed.” d. “Psychiatric institutions are no longer popular as a consequence of negative stories in the press.” ANS: B The community is a less restrictive alternative than hospitals for the treatment of people with mental illness. The remaining options are incorrect and part of the stigma of mental illness. DIF: Cognitive Level: Application REF: Page: 82 TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment 7. Which nursing intervention demonstrates false imprisonment?a. A confused and combative patient says, “I’m getting out of here and no one can stop me.” The nurse restrains this patient without a health care provider’s order and then promptly obtains an order. b. A patient has been irritating, seeking the attention of nurses most of the day. Now a nurse escorts the patient down the hall saying, “Stay in your room or you’ll be put in seclusion.” c. An involuntarily hospitalized patient with suicidal ideation runs out of the psychiatric unit. A nurse rushes after the patient and convinces the patient to return to the unit. d. An involuntarily hospitalized patient with suicidal ideation attempts to leave the unit. A nurse calls the security team and uses established protocols to prevent the patient from leaving. ANS: B False imprisonment involves holding a competent person against his or her will. Actual force is not a requirement of false imprisonment. The individual needs only to be placed in fear of imprisonment by someone who has the ability to carry out the threat. The patient in one distracter is not competent, and the nurse is acting beneficently. The patients in the other distracters have been admitted as involuntary patients and should not be allowed to leave without permission of the treatment team. DIF: Cognitive Level: Application REF: Pages: 88-89 TOP: Nursing Process: Evaluation MSC: NCLEX: Safe, Effective Care Environment 8. A patient should be considered for involuntary commitment for psychiatric care when he or she: a. is noncompliant with the treatment regimen. b. sold sells and distributes illegal drugs. c. threatens to harm self and others. d. fraudulently files for bankruptcy. ANS: C Involuntary commitment protects patients who are dangerous to themselves or others and cannot care for their own basic needs. Involuntary commitment also protects other individuals in society. The behaviors described in the other options are not sufficient to require involuntary hospitalization.DIF: Cognitive Level: Comprehension REF: Pages: 82-83 TOP: Nursing Process: Assessment MSC: NCLEX: Safe, Effective Care Environment 9. A nurse at the mental health center prepares to administer a scheduled injection of haloperidol decanoate (Haldol depot injection) to a patient with schizophrenia. As the nurse swabs the site, the patient shouts, “Stop, stop! I don’t want to take that medicine anymore. I hate the side effects.” Select the nurse’s best initial action. a. Stop the medication administration procedure and say to the patient, “Tell me more about the side effects you’ve been having.” b. Say to the patient, “Since I’ve already drawn the medication in the syringe, I’m required to give it, but let’s talk to the doctor about skipping next month’s dose.” c. Proceed with the injection but explain to the patient that other medications are available that may help reduce the unpleasant side effects. d. Notify other staff members to report to the room for a show of force and proceed with the injection, using restraint if necessary. ANS: A Patients with mental illness retain their civil rights unless clear, cogent, and convincing evidence of dangerousness exists. The patient in this situation presents no evidence of being dangerous. The nurse, an as advocate and educator, should seek more information about the patient’s decision and should not force the medication. DIF: Cognitive Level: Analysis REF: Pages: 84-85 TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment 10. Several nurses are concerned that agency policies related to restraint and seclusion practices are inadequate. Which statement about the relationship of substandard institutional policies and individual nursing practice should guide nursing practice? a. The policies do not absolve an individual nurse of the responsibility to practice according to the professional standards of nursing care. b. Agency policies are the legal standard by which a professional nurse must act and therefore override other standards of care. c. In an institution with substandard policies, the nurse has a responsibility to inform the supervisor and leave the premises. d. Interpretation of policies by the judicial system is rendered on an individual basis and therefore cannot be a professional nurse must act and therefore override other standards of care. c. In an institution with substandard policies, the nurse has a responsibility to inform the supervisor and leave the premises. d. Interpretation of policies by the judicial system is rendered on an individual basis and therefore cannot be predicted. ANS: A Nurses are professionally bound to uphold the American Nurses Association (ANA) standards of practice, regardless of lesser standards established by a health care agency or state. Conversely, if the agency standards are higher than the ANA standards of practice, the agency standards must be upheld. The courts may seek to establish the standard of care through the use of expert witnesses when the issue is clouded. DIF: Cognitive Level: Application REF: Pages: 90-91 TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment 11. A newly admitted patient who is acutely psychotic is a private patient of the senior psychiatrist. To whom does the psychiatric nurse who is assigned to this patient owe the duty of care? a. Health care provider b. Profession c. Hospital d. Patient ANS: D Although the nurse is accountable to the health care provider, the agency, the patient, and the profession, the duty of care is owed to the patient. DIF: Cognitive Level: Application REF: Pages: 90-91 TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment 12. An example of a breach of a patient’s right to privacy occurs when a nurse: a. asks a family to share information about a patient’s prehospitalization behavior. b. discusses the patient’s history with other staff members during care planning. c. documents the patient’s daily behaviors during hospitalization. d. releases information to the patient’s employer without consent. ANS: D The release of information without patient authorization violates the patient’s right to privacy. The other options are acceptable nursing practices. DIF: Cognitive Level: Application REF: Page: 83|Pages: 85-87|Pages: 92-93 TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment 13. An adolescent hospitalized after a violent physical outburst tells the nurse,“I’m going to kill my father, but you can’t tell anyone.” Select the nurse’s best response. a. “You’re right. Federal law requires me to keep that information private.” b. “Those kinds of thoughts will make your hospitalization longer.” c. “You really should share this thought with your psychiatrist.” d. “I am obligated to share information with the treatment team.” ANS: D Breach of nurse-patient confidentiality does not pose a legal dilemma for nurses in these circumstances because a team approach to the delivery of psychiatric care presumes communication of patient information to other staff members to develop treatment plans and outcome criteria. The patient should know that the team may have to warn the father of the risk for harm. DIF: Cognitive Level: Application REF: Page: 87 TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment 14. A voluntarily hospitalized patient tells the nurse, “Get me the forms for discharge against medical advice so I can leave now.” What is the nurse’s best initial response? a. “I can’t give you those forms without your health care provider’s knowledge.” b. “I will get them for you, but let’s talk about your decision to leave treatment.” c. “Since you signed your consent for treatment, you may leave if you desire.” d. “I’ll get the forms for you right now and bring them to your room.” ANS: B A patient who has been voluntarily admitted as a psychiatric inpatient has the right to demand and obtain release in most states. However, as a patient advocate, the nurse is responsible for weighing factors related to the patient’s wishes and best interests. By asking for information, the nurse may be able to help the patient reconsider the decision. The statement that discharge forms cannot be given without the health care provider’s knowledge is not true. Facilitating discharge without consent is not in the patient’s best interest before exploring the reason for the request. DIF: Cognitive Level: Application REF: Page: 83 TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment 15. The family of a patient whose insurance will not pay for continuing hospitalization considers transferring the patient to a public psychiatric hospital. The family expresses concern that the patient will “never get any treatment.” Which reply bythe nurse would be most helpful? a. “Under the law, treatment must be provided. Hospitalization without treatment violates patients’ rights.” b. “That’s a justifiable concern because the right to treatment extends only to the provision of food, shelter, and safety.” c. “Much will depend on other patients because the right to treatment for a psychotic patient takes precedence over the right to treatment of a patient who is stable.” d. “All patients in public hospitals have the right to choose both a primary therapist and a primary nurse.” ANS: A The right to medical and psychiatric treatment was conferred on all patients hospitalized in public mental hospitals with the enactment of the federal Hospitalization of Mentally Ill Act in 1964. Stating that the concern is justifiable supports the family’s erroneous belief. The provisions mentioned in the third and fourth options are not part of this or any other statute governing psychiatric care. DIF: Cognitive Level: Application REF: Pages: 83-84 TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment 16. Which individual with a mental illness may need emergency or involuntary hospitalization for mental illness? The individual who: a. resumes using heroin while still taking methadone. b. reports hearing angels playing harps during thunderstorms. c. throws a heavy plate at a waiter at the direction of command hallucinations. d. does not show up for an outpatient appointment with the mental health nurse. ANS: C Throwing a heavy plate is likely to harm the waiter and is evidence of being dangerous to others. This behavior meets the criteria for emergency or involuntary hospitalization for mental illness. The behaviors in the other options evidence mental illness but not dangerousness. DIF: Cognitive Level: Application REF: Pages: 82-83 TOP: Nursing Process: Analysis| Nursing Process: Diagnosis MSC: NCLEX: Safe, Effective Care Environment17. A patient being treated in an alcohol rehabilitation unit reveals to the nurse, “I feel terrible guilt for sexually abusing my 6-year-old child before I was admitted.” Based on state and federal law, the best action for the nurse to take is to: a. anonymously report the abuse by telephone to the local child abuse hotline. b. reply, “I’m glad you feel comfortable talking to me about it.” c. respect nurse-patient relationship of confidentiality. d. file a written report on the agency letterhead. ANS: A Laws regarding reporting child abuse discovered by a professional during a suspected abuser’s alcohol or drug treatment differ by state. Federal law supersedes state law and prohibits disclosure without a court order except in instances in which the report can be made anonymously or without identifying the abuser as a patient in an alcohol or drug treatment facility. Anonymously reporting the abuse by telephone to the local child abuse hotline meets federal criteria. Respecting nurse-patient confidentiality and replying, “I’m glad you feel comfortable talking to me about it” do not accomplish reporting. Filing a written report on agency letterhead violates federal law. DIF: Cognitive Level: Analysis REF: Page: 88 TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment 18. The spouse of a patient who has delusions asks the nurse, “Are there any circumstances under which the treatment team is justified in violating the patient’s right to confidentiality?” The nurse must reply that confidentiality may be breached: a. under no circumstances. b. at the discretion of the psychiatrist. c. when questions are asked by law enforcement. d. if the patient threatens the life of another person. ANS: D The duty to warn a person whose life has been threatened by a patient under psychiatric treatment overrides the patient’s right to confidentiality. The right to confidentiality is not suspended at the discretion of the therapist or for legal investigations. DIF: Cognitive Level: Comprehension REF: Page: 87 TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment 19. A nurse cares for an older adult patient admitted for the treatment of depression. The health care provider prescribes an antidepressant medication, but the dose is more than the usual adult dose. The nurse should: a. implement the order. b. consult a drug reference. c. give the usual geriatric dosage. d. hold the medication and consult the health care provider.a. implement the order. b. consult a drug reference. c. give the usual geriatric dosage. d. hold the medication and consult the health care provider. ANS: D The dose of an antidepressant medication for older adult patients is often less than the usual adult dose. The nurse should withhold the medication and consult the health care provider who wrote the order. The nurse’s duty is to intervene and protect the patient. Consulting a drug reference is unnecessary because the nurse already knows the dose is excessive. Implementing the order is negligent. Giving the usual geriatric dose would be wrong; a nurse without prescriptive privileges cannot change the dose. DIF: Cognitive Level: Application REF: Pages: 88-89 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 20. A patient with paranoid schizophrenia believes evil spirits are being summoned by a local minister and verbally threatens to bomb a local church. The psychiatrist notifies the minister. The psychiatrist has: a. released information without proper authorization. b. demonstrated the duty to warn and protect. c. violated the patient’s confidentiality. d. avoided charges of malpractice. ANS: B The duty of a health care professional is to warn or notify an intended victim after a threat of harm has been made. Informing a potential victim of a threat is a legal responsibility of the health care professional and not considered a violation of confidentiality. DIF: Cognitive Level: Application REF: Page: 87 TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment 21. After leaving work, a staff nurse realizes that documentation of the administration of a medication to a patient was omitted. This off-duty nurse telephones the unit and tells the nurse, “Please document the administration of the medication I forgot to do. My password is alpha1.” The nurse should: a. fulfill the request. b. refer the matter to the charge nurse to resolve. c. access the record and document the information. d. report the request to the patient’s health care provider. ANS: BAt most hospitals, termination is a possible penalty for unauthorized entry into a patient record. Referring the matter to the charge nurse will allow the observance of hospital policy while ensuring that documentation occurs. Making an exception and fulfilling the request places the on-duty staff nurse in jeopardy. Reporting the request to the patient’s health care provider would be unnecessary. Accessing the record and documenting the information would be unnecessary when the charge nurse can resolve the problem. DIF: Cognitive Level: Application REF: Pages: 92-93 TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment 22. A patient with mental illness asks a psychiatric technician, “What’s the matter with me?” The technician replies, “Your wing nuts need tightening.” The patient looks bewildered and wanders off. The nurse who overheard the exchange should take action based on: a. violation of the patient’s right to be treated with dignity and respect. b. the nurse’s obligation to report caregiver negligence. c. preventing defamation of the patient’s character. d. supervisory liability. ANS: A Patients have the right to be treated with dignity and respect. Patients should never be made the butt of jokes about their illness. Patient emotional abuse has been demonstrated, not negligence. The technician’s response was not clearly defamation. Patient abuse, not supervisory liability, is the issue. DIF: Cognitive Level: Comprehension REF: Page: 86 TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment 23. Which documentation of a patient’s behavior best demonstrates a nurse’s observations? a. Isolates self from others. Frequently fell asleep during group. Vital signs stable. b. Calmer and more cooperative. Participated actively in group. No evidence of psychotic thinking. c. Appeared to hallucinate. Patient frequently increased volume on television, causing conflict with others d. Wears four layers of clothing. States, “I need protection from dangerous bacteria trying to penetrate my skin.” ANS: DThe documentation states specific observations of the patient’s appearance and the exact statements made. The other options are vague or subjective statements and can be interpreted in different ways. DIF: Cognitive Level: Application REF: Page: 92 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity MULTIPLE RESPONSE 1. A nurse volunteers for a committee that must revise the hospital policies and procedures for suicide precautions. Which resources would provide the best guidance? Select all that apply. a. Diagnostic and Statistical Manual of Mental Disorders (fourth edition, text revision) (DSM-IV-TR) b. State’s nurse practice act c. State and federal regulations that govern hospitals d. Summary of common practices of several local hospitals e. American Nurses Association Scope and Standards of Practice for Psychiatric– Mental Health Nursing Practice ANS: C, E Regulations regarding hospitals provide information about the minimal standard. The American Nurses Association (ANA) national standards focus on elevating practice by setting high standards for nursing practice. The DSM-IV-TR and the state’s nurse practice act would not provide relevant information. A summary of common practices of several local hospitals cannot be guaranteed to be helpful because the customs may or may not comply with laws or best practices. DIF: Cognitive Level: Analysis REF: Page: 82|Page: 87|Page: 90 TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment 2. In which situations does a nurse have a duty to intervene and report? Select all that apply. a. A peer is unable to write behavioral outcomes. b. A health care provider consults the Physicians’ Desk Reference. c. A peer tries to provide patient care in an alcohol-impaired state. d. A team member has violated the boundaries of a vulnerable patient. e. A patient refuses a medication prescribed by a licensed health care provider.Physicians’ Desk Reference. c. A peer tries to provide patient care in an alcohol-impaired state. d. A team member has violated the boundaries of a vulnerable patient. e. A patient refuses a medication prescribed by a licensed health care provider. ANS: C, D Both instances jeopardize patient safety. The nurse must practice within the Code of Ethics for Nurses. A peer being unable to write behavioral outcomes is a concern but can be informally resolved. A health care provider consulting the Physicians’ Desk Reference is acceptable practice. DIF: Cognitive Level: Application REF: Page: 86|Page: 91 TOP: Nursing Process: Evaluation MSC: NCLEX: Safe, Effective Care Environment 3. Which situations qualify as abandonment on the part of a nurse? (Select all that apply.) The nurse: a. allows a patient with acute mania to refuse hospitalization without taking further action. b. terminates employment without referring a seriously mentally ill for aftercare. c. calls police to bring a suicidal patient to the hospital after a suicide attempt. d. refers a patient with persistent paranoid schizophrenia to community treatment. e. asks another nurse to provide a patient’s care because of concerns about countertransference. ANS: A, B Abandonment arises when a nurse does not place a patient safely in the hands of another health professional before discontinuing treatment. Calling the police to bring a suicidal patient to the hospital after a suicide attempt and referring a patient with schizophrenia to community treatment both provide for patient safety. Asking another nurse to provide a patient’s care because of concerns about countertransference demonstrates selfawareness. DIF: Cognitive Level: Application REF: Page: 91 TOP: Nursing Process: Evaluation MSC: NCLEX: Safe, Effective Care EnvironmentChapter 7: Nursing Process and QSEN: The Foundation for Safe and Effective Care Test Bank MULTIPLE CHOICE 1. 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 medications. d. Individualize nursing care plans. ANS: C 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. DIF: Cognitive Level: Comprehension REF: Page: 109 TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment 2. A newly admitted patient with major depression has lost 20 pounds over the past month and has suicidal ideation. 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 ANS: C 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. DIF: Cognitive Level: Application REF: Page: 105 TOP: Nursing Process: Diagnosis| Nursing Process: Analysis MSC: NCLEX: Psychosocial Integrity 3. A patient with major depression has lost 20 pounds in one month has chronic low self-esteem and a plan for suicide. The patient has taken an antidepressant medication for 1 week. Which nursing intervention is most directly related to this outcome: “Patient will refrain from gestures and attempts to harm self”?a. Implement suicide precautions. b. Frequently offer high-calorie snacks and fluids. c. Assist the patient to identify three personal strengths. d. Observe patient for therapeutic effects of antidepressant medication. ANS: A Implementing suicide precautions is the only option related to patient safety. The other options, related to nutrition, self-esteem, and medication therapy, are important but are not priorities. DIF: Cognitive Level: Application REF: Pages: 105-106 TOP: Nursing Process: Planning MSC: NCLEX: Safe, Effective Care Environment 4. 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 ANS: D 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. DIF: Cognitive Level: Application REF: Page: 110 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 5. 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. What is the nurse’s next action? a. Continue the current plan without changes. b. Remove this nursing diagnosis from the plan of care. c. Write a new nursing diagnosis that better reflects the problem. d. Revise the target date for outcome attainment and examine interventions. ANS: DSleeping a total of 5 hours at night remains a reasonable outcome. Extending the time frame for attaining the outcome is appropriate. Examining interventions might result in planning an activity during the afternoon rather than permitting a nap. Continuing the current plan without changes is inappropriate. At the very least, the time in which the outcome is to be attained must be extended. Removing this nursing diagnosis from the plan of care could be used when the outcome goal has been met and the problem resolved. Writing a new nursing diagnosis is inappropriate because no other nursing diagnosis relates to the problem. DIF: Cognitive Level: Application REF: Page: 110 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 6. 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 ANS: D Interventions are the nursing prescriptions to achieve the outcomes. Interventions should be specific. DIF: Cognitive Level: Application REF: Page: 109 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 7. Before assessing a new patient, a nurse is told by another health care worker, “I know that patient. No matter how hard we work, there isn’t much improvement by the time of discharge.” The nurse’s responsibility is to: a. document the other worker’s assessment of the patient. b. assess the patient based on data collected from all sources. c. validate the worker’s impression by contacting the patient’s significant other. d. discuss the worker’s impression with the patient during the assessment interview. ANS: B Assessment should include data obtained from both the primary and reliable secondary sources. Biased assessments by others should be evaluated as objectively as possible by the nurse, keeping in mind the possible effects of counter-transference.DIF: Cognitive Level: Application REF: Pages: 98-99|Pages: 103-105 TOP: Nursing Process: Assessment MSC: NCLEX: Safe, Effective Care Environment 8. A nurse works with a patient to establish outcomes. The nurse believes that one outcome suggested by the patient is not in the patient’s best interest. What is the nurse’s best action? a. Remain silent. b. Educate the patient that the outcome is not realistic. c. Explore with the patient possible consequences of the outcome. d. Formulate an appropriate outcome without the patient’s input. ANS: C The nurse should not impose outcomes on the patient; however, the nurse has a responsibility to help the patient evaluate what is in his or her best interest. Exploring possible consequences is an acceptable approach. DIF: Cognitive Level: Application REF: Pages: 105-108 TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment 9. 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 precautions ANS: D 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. The nurse should monitor and reinforce all patient attempts to control anxiety, improve sleep patterns, and develop self-esteem while giving priority attention to suicide self-restraint. DIF: Cognitive Level: Analysis REF: Pages: 108-109 TOP: Nursing Process: Planning MSC: NCLEX: Safe, Effective Care Environment 10. Select the best outcome for a patient with the nursing diagnosis: Impaired social interaction, related to sociocultural dissonance as evidenced by stating, “Although I’d like to, I don’t join in because I don’t speak the language very well.” The patient will: a. demonstrate improved social skills. b. express a desire to interact with others. c. become more independent in decision making. d. select and participate in one group activity per day.a. demonstrate improved social skills. b. express a desire to interact with others. c. become more independent in decision making. d. select and participate in one group activity per day. ANS: D The outcome describes social involvement on the part of the patient. Neither cooperation nor independence has been an issue. The patient has already expressed a desire to interact with others. Outcomes must be measurable. Two of the distracters are not measurable. DIF: Cognitive Level: Analysis REF: Pages: 105-106 TOP: Nursing Process: Outcomes Identification MSC: NCLEX: Psychosocial Integrity 11. Nursing behaviors associated with the implementation phase of the nursing process are concerned with: a. participating in the mutual identification of patient outcomes. b. gathering accurate and sufficient patientcentered data. c. comparing patient responses and expected outcomes. d. carrying out interventions and coordinating care. ANS: D Nursing behaviors relating to implementation include using available resources, performing interventions, finding alternatives when necessary, and coordinating care with other team members. DIF: Cognitive Level: Comprehension REF: Page: 109 TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment 12. 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.” ANS: D 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. DIF: Cognitive Level: Analysis REF: Pages: 101-103 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity13. 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 (Prolixin) 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 (Haldol) 2 mg . I: (Haldol) 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 (Haldol) 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 (Haldol) 2 mg administered at 0900 with calming effect in 30 minutes. Stated, ‘I’m no longer bothered by the voices.’” ANS: B 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. The distracters offer examples of PIE charting, focus documentation, and narrative documentation. DIF: Cognitive Level: Analysis REF: Page: 111 TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment 14. A nurse assesses an older adult patient brought to the emergency department by a family member. The patient was wandering outside, saying, “I can’t find my way home.” The patient is confused and unable to answer questions. Select the nurse’s best action. a. Document the patient’s mental status. Obtain other assessment data from the family member. b. Record the patient’s answers to questions on the nursing assessment form. c. Ask an advanced practice nurse to perform the assessment interview. d. Call for a mental health advocate to maintain the patient’s rights.a. Document the patient’s mental status. Obtain other assessment data from the family member. b. Record the patient’s answers to questions on the nursing assessment form. c. Ask an advanced practice nurse to perform the assessment interview. d. Call for a mental health advocate to maintain the patient’s rights. ANS: A When the patient (primary source) is unable to provide information, secondary sources should be used, in this case the family member. Later, more data may be obtained from other relatives or neighbors who are familiar with the patient. An advanced practice nurse is not needed for this assessment; it is within the scope of practice of the staff nurse. Calling a mental health advocate is unnecessary. DIF: Cognitive Level: Application REF: Pages: 98-101 TOP: Nursing Process: Assessment MSC: NCLEX: Safe, Effective Care Environment 15. A nurse asks a patient, “If you had fever and vomiting for 3 days, what would you do?” Which aspect of the mental status examination is the nurse assessing? a. Behavior b. Cognition c. Affect and mood d. Perceptual disturbances ANS: B Assessing cognition involves determining a patient’s judgment and decision-making capabilities. In this case, the nurse expects a response of, “Call my doctor” if the patient’s cognition and judgment are intact. If the patient responds, “I would stop eating” or “I would just wait and see what happened,” the nurse would conclude that judgment is impaired. The other options refer to other aspects of the examination. DIF: Cognitive Level: Application REF: Pages: 101-103 TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 16. An adolescent asks a nurse conducting an assessment interview, “Why should I tell you anything? You’ll just tell my parents whatever you find out.” Select the nurse’s best reply. a. “That isn’t true. What you tell us is private and held in strict confidence. Your parents have no right to know.” b. “Yes, your parents may find out what you say, but it is important that they know about your problems.” c. “What you say about feelings is private, but some things, like suicidal thinking, must be reported to the treatment team.” d. “It sounds as though you are not really ready to work on your problems and make changes.”say, but it is important that they know about your problems.” c. “What you say about feelings is private, but some things, like suicidal thinking, must be reported to the treatment team.” d. “It sounds as though you are not really ready to work on your problems and make changes.” ANS: C The patient has a right to know that most information will be held in confidence but that certain material must be reported or shared with the treatment team, such as threats of suicide, homicide, use of illegal drugs, or issues of abuse. The first response is not strictly true. The second response will not inspire the confidence of the patient. The fourth response is confrontational. DIF: Cognitive Level: Application REF: Pages: 100-101 TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment 17. A nurse assessing a new patient asks, “What is meant by the saying, ‘You can’t judge a book by its cover’?” Which aspect of cognition is the nurse assessing? a. Mood b. Attention c. Orientation d. Abstraction ANS: D Patient interpretation of proverbial statements gives assessment information regarding the patient’s ability to abstract, which is an aspect of cognition. Mood, orientation, and attention span are assessed in other ways. DIF: Cognitive Level: Application REF: Pages: 101-103 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 18. When a nurse assesses an older adult patient, answers seem vague or unrelated to the questions. The patient also leans forward and frowns, listening intently to the nurse. An appropriate question for the nurse to ask would be: 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?” ANS: A 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. By asking if the patient is annoyed, the nurse is jumping to conclusions. Asking how to make the interview easier for the patient may not elicit a concrete answer. Asking about distractions is a way of asking about auditory hallucinations, which is notappropriate because the nurse has observed that the patient seems to be listening intently. DIF: Cognitive Level: Application REF: Pages: 100-101 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 19. At what point in an assessment interview would a nurse ask, “How does your faith help you in stressful situations?” During the assessment of: a. childhood growth and development. b. substance use and abuse. c. educational background. d. coping strategies. ANS: D 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. It would seem out of place if introduced during exploration of the other topics. DIF: Cognitive Level: Application REF: Pages: 101-104 TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 20. When a new patient is hospitalized, a nurse takes the patient on a tour, explains the rules of the unit, and discusses the daily schedule. The nurse is engaged in: a. counseling. b. health teaching. c. milieu management. d. psychobiologic intervention. ANS: C Milieu management provides a therapeutic environment in which the patient can feel comfortable and safe while engaging in activities that meet the patient’s physical and mental health needs. Counseling refers to activities designed to promote problem solving and enhanced coping and includes interviewing, crisis intervention, stress management, and conflict resolution. Health teaching involves identifying health educational needs and giving information about these needs. Psychobiologic interventions involve medication administration and monitoring response to medications. DIF: Cognitive Level: Comprehension REF: Page: 109 TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment 21. After formulating the nursing diagnoses for a new patient, what is the next action a nurse should take? a. Design interventions to include in the plan of care. b. Determine the goals and outcome criteria. c. Implement the nursing plan of care. d. Complete the spiritual assessment.a. Design interventions to include in the plan of care. b. Determine the goals and outcome criteria. c. Implement the nursing plan of care. d. Complete the spiritual assessment. ANS: B The third step of the nursing process is planning and outcome identification. Outcomes cannot be determined until the nursing assessment is complete and the nursing diagnoses have been formulated. DIF: Cognitive Level: Comprehension REF: Pages: 105-106 TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment 22. 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 ANS: D Nursing diagnoses are selected on the basis of the etiologic factors and assessment findings or evidence. In this instance, the evidence shows social isolation that is caused by shyness and poorly developed social skills. DIF: Cognitive Level: Application REF: Pages: 105-106 TOP: Nursing Process: Diagnosis| Nursing Process: Analysis MSC: NCLEX: Psychosocial Integrity 23. The acronym QSEN refers to: a. Qualitative Standardized Excellence in Nursing. b. Quality and Safety Education for Nurses. c. Quantitative Effectiveness in Nursing. d. Quick Standards Essential for Nurses. ANS: B 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. DIF: Cognitive Level: Knowledge REF: Pages: 97-98 TOP: Nursing Process: N/A MSC: NCLEX: Safe, Effective Care Environment 24. A nurse documents: “Patient is mute, despite repeated efforts to elicit speech. Makes no eye contact. Is inattentive to staff. Gazes off to the side or looks upward rather than at the speaker.” Which nursing diagnosis should be considered? a. Defensive coping b. Decisional conflict c. Risk for other-directed violence d. Impaired verbal communicationa. Defensive coping b. Decisional conflict c. Risk for other-directed violence d. Impaired verbal communication ANS: D The defining characteristics are more related to the nursing diagnosis of Impaired verbal communication than to the other nursing diagnoses. DIF: Cognitive Level: Application REF: Pages: 105-106 TOP: Nursing Process: Diagnosis| Nursing Process: Analysis MSC: NCLEX: Psychosocial Integrity MULTIPLE RESPONSE 1. A nurse assesses a patient who reluctantly participates in activities, answers questions with minimal responses, and rarely makes eye contact. What information should be inclu

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