Fortinash: Psychiatric Mental Health Nursing, 5th Edition

Chapter 03: The Nursing Process and Standards o Practice Test !an" M#$T%P$E CH&%CE 1. The patient asks the nurse, Ive heard the student nurses talk about the nursing process. Why is there so much emphasis on using the nursing process? The response that e plains the need !or nurses to understand and use the nursing process is" a #o you think you have a better method $e might use? . b The nursing process is a systematic problem%solving method encompassing all . components necessary to care !or patients. c &sing the nursing process is a $ay o! legitimi'ing our pro!ession and placing us . on an e(ual !ooting $ith the pure sciences. d The nursing process is a unidimensional, static, linear approach used to guide . nurses as they make clinical )udgments. *+," This response best e plains the importance o! the nursing process by description and relationship to patient care. ,uggesting that the patient may have a better method is challenging and does not address the (uestion posed by the patient. .roviding legitimacy to the pro!ession is a very limited e planation !or use o! the nursing process. The nursing process is not one%dimensional, static, or linear. #I/" 0ognitive 1evel" 2no$ledge 34/" .age 56 T7." +ursing .rocess" Implementation 8,0" +0149" ,a!e and 4!!ective 0are 4nvironment :. When preparing to conduct a nursing history and assessment on a patient trans!erred !rom the emergency department ;4#< $hose !amily believes the patient to be a (uestionable historian due to cognitive impairment, the nurse initially begins the intervie$ by" a 3evie$ing the 4# chart . b 0ontacting the admitting physician . c #irecting the (uestions to the !amily members . d 4stablishing a line o! communication $ith the patient . *+," # The nurse should begin establishing the nurse=patient relationship by initially directing the (uestions to the patient. The nurse can con!irm in!ormation and>or obtain supplementary in!ormation !rom the sources identi!ied by the other options.
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#I/" 0ognitive 1evel" *pplication T7." +ursing .rocess" *ssessment 4nvironment

34/" .age 56 8,0" +0149" ,a!e and 4!!ective 0are

A. The nurse sho$s the ability to e!!ectively state a nursing diagnosis re!lective o! the implications o! depression on a patients li!e processes $hen stating in the patients plan o! care that" a .atient outcomes $ere partially attained. Implementation o! present plan to . continue. b .atient $ill initiate and support conversation $ith nurse therapist by ;date A . $eeks in !uture<. c 7ral medication !or an iety should be administered $hen depression is assessed . to be at the moderate level. d Impaired verbal communication r>t impoverished thoughts secondary to . depression as evidenced by monosyllabic responses. *+," # This statement contains the various components o! a nursing diagnosis $hile e pressing the e istence o! an altered li!e process. The remaining options re!lect other steps, such as evaluation and intervention planning. #I/" 0ognitive 1evel" *pplication 34/" .ages 5@%5B T7." +ursing .rocess" *nalysis 8,0" +0149" ,a!e and 4!!ective 0are 4nvironment 5. a . b . c . d . When engaging in outcomes identi!ication, the nurse" Intervie$s and collects patient%!ocused data 3e%assesses the patients physical and emotional status evaluation 3evie$s the patients e isting problems and pro)ects the results o! the nursing care 0onsiders the patients presenting symptoms and identi!ies nursing%related problems

*+," 0 7utcomes are pro)ections o! e pected in!luence that nursing interventions $ill have on the patient. Intervie$ing and collecting data is involved in the assessment process, re%assessing is involved in the evaluation process, and identi!ying related nursing problems is involved in determining appropriate nursing diagnoses. #I/" 0ognitive 1evel" *pplication 34/" .age 5C T7." +ursing .rocess" Implementation 8,0" +0149" ,a!e and 4!!ective 0are 4nvironment

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D. While discussing assessment o! suicidal patients, a novice nurse mentions, I $as taught to al$ays base my care on concrete, evidence%based scienti!ic reasoning and never to rely on intuition. Which response by the e perienced nurse sho$s understanding o! intuitive reasoning? a Thats $ise, because intuition $ent out o! !avor $ith the scienti!ic revolution. . b 0ritical thinking and intuition are at opposite poles. 2eep relying on your . e pertise. c Its possible that intuition about suicidality is generated by trans!er o! !eelings . !rom the patient to the nurse. d Its been determined that intuition is nothing more that e trasensory perception, . so some !olks have it, and some dont. *+," 0 * strong hunch or a gut !eeling is an e ample o! intuitive reasoning that is believed to come !rom the therapeutic relationships sharing o! !eelings bet$een nurse and patient. 8ost nurses agree that intuition is compatible $ith scienti!ic reasoning, because both are likely linked to practice and e perience. * nurse learns intuitive reasoning through clinical practice rather than !rom school or books. #I/" 0ognitive 1evel" *pplication 34/" .age 5D T7." +ursing .rocess" *nalysis ;0aring< 8,0" +0149" ,a!e and 4!!ective 0are 4nvironment E. * nurse sho$s e!!ective critical thinking skills directed to$ards nursing care o! a cognitively impaired patient $ho continues to socially isolate by" a 0learly stating that the patient must socially interact once daily . b #ocumenting that the patient continues to resist sociali'ation . c *sking the patient to identi!y $hich unit activity they are $illing to attend . d ,uggesting that sta!! take the patient $ith them $hen running errands o!! the unit . *+," # 0ritical thinking in this case involves the creation o! alternative solutions to a problem that $as not resolved by conventional methods. The remaining options, although not inappropriate, do not sho$ critical thinking skills #I/" 0ognitive 1evel" *pplication 34/" .age 5D .lanning 8,0" +0149" ,a!e and 4!!ective 0are 4nvironment T7." +ursing .rocess"

@. * depressed patient shares $ith the nurse that he, has been thinking about ending it all. -ased on +*+#* recommendations, the nurse"

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Test -ank a . b . c . d . Implements suicide precautions !or this patient Includes F3isk !or ,el! Garm to the patients care plan #ocuments regarding the patients sa!ety every 1D minutes 3evie$s the patients chart !or re!erences to past incidences o! hopeless

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*+," +*+#* states that a nurse is able to change any actual diagnosis on the +*+#* list to a risk diagnosis i! the problem has not occurred yet. The remaining options, although not inappropriate, do not related to +*+#*. #I/" 0ognitive 1evel" *pplication 34/" .age 5B *nalysis 8,0" +0149" ,a!e and 4!!ective 0are 4nvironment T7." +ursing .rocess"

B. The nurse sho$s an understanding o! the appropriate use o! nursing outcomes regarding triggers !or a patient diagnosed $ith chronic alcohol abuse $hen stating" a H0an you $ork on identi!ying three situations that cause you to abuse alcohol? . b Ill help you to identi!y three triggers !or your drinking during todays session. . c Im pleased youve identi!ied three situations that trigger your abuse o! alcohol. . d #o you think you $ill be able to avoid the three triggers that cause you to . drink? *+," 0 7utcomes sometimes re!erred to as behavioral goals are used to describe and evaluate the e!!ectiveness o! nursing interventions. The correct option sho$s that the patient $as success!ul at accomplishing an outcome in!erring the nursing interventions $ere success!ul. The remaining options do not indicate an evaluation o! success or !ailure. #I/" 0ognitive 1evel" *pplication 34/" .age 5C T7." +ursing .rocess" 4valuation 8,0" +0149" .sychosocial Integrity" 0hemical and 7ther #ependencies C. When a patient e periencing acute depression asks $hat the di!!erence is bet$een a medical and a nursing diagnosis, the nurse responds best $hen stating" a *ctually they are very similar in that they both are concerned $ith helping you . get better and lead a happier li!e. b 8edical diagnoses are !ocused on $hy you are depressed $hereas nursing . diagnoses are concerned about making your li!e less sad. c +ursing diagnoses are more directed at caring !or you, unlike medical diagnoses

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Test -ank . that !ocus on !inding the cause !or your problem. d The medical diagnosis identi!ies that you are e periencing depression $hereas . the nursing diagnosis identi!ies ho$ the depression is a!!ecting you.

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*+," # The medical diagnosis involves identi!ying a mental or physical problem that results in the symptoms that negatively a!!ect a patients li!e. *lthough the nurse is kno$ledgeable about the disorders and their treatments, the nursing diagnosis !ocuses mainly on the patients responses to the disorder and the e!!ects that the disorder has on the patient. The types o! diagnoses have di!!erent !oci that result in di!!erent actions and concerns. #I/" 0ognitive 1evel" *pplication 34/" .age 5C T7." +ursing .rocess" Implementation ;Teaching and 1earning< 8,0" +0149" .sychosocial Integrity" Therapeutic 0ommunication 16. * nurse best sho$s an understanding o! the role o! evidence%based research in achieving therapeutic patient care outcomes $hen" a ,ubscribing to and reading a monthly psychiatric research nursing )ournal . b Working on a committee to revise current !acility policies regarding the use o! . chemical restraints c 3egistering to attend a psychiatric $orkshop on ne$ly developed psychotropic . medication therapies d *sking an e perienced sta!! member to revie$ the interventions being proposed . !or a ne$ly admitted patient *+," 4vidence%based practice is based on evidence and scienti!ic principles that have been developed through research. The more closely clinical practice re!lects relevant research, the more likely it is that patients $ill receive the best available care. The option that in!ers action directed at implementing the research is the one that sho$s best understanding. 3eliance only on e perience is not re!lective o! (uality nursing care. #I/" 0ognitive 1evel" *pplication 34/" .age D1 .lanning 8,0" +0149" ,a!e and 4!!ective 0are 4nvironment T7." +ursing .rocess"

11. When caring !or a patient admitted $ith a diagnosis i! bipolar disorder, managed care regulations is the driving !orce behind the nurses use o!" a +*+#* nursing diagnoses . b ,hort%term stress management therapy . c * speciali'ed clinical path$ay !or such patients . d Ieneric instead o! brand name medications

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*+," 0 8anaged care regulations have brought about the use o! clinical path$ays ;also called critical pathways or a care maps< $hich are standardi'ed multidisciplinary planning tools that monitor patient care through pro)ected caregiver interventions and e pected patient outcomes $ith a pro)ected timeline o! success. +*+#* nursing diagnoses are not related to regulations or payment concerns. The implementation o! short%term stress management therapy in an acute care psychiatric environment $ould not be driven by managed care regulation or payment concerns. The use o! generic medications $hen appropriate is primarily cost driven. #I/" 0ognitive 1evel" *pplication 34/" .age D1 T7." +ursing .rocess" Implementation 8,0" +0149" ,a!e and 4!!ective 0are 4nvironment 1:. * bene!it o! the implementation o! clinical path$ays is evidenced $hen the patient states" a I kno$ my doctors and nurses really care about me. . b 8y medication has really helped lessen my symptoms. . c I have hopes that I $ill be able to lead a productive, healthy li!e. . d 8y care team has really helped me manage most o! my problems. . *+," # 0linical path$ays are tools that among other things promote interdisciplinary care thus providing !or holistic care o! the patient. The remaining options do not involve the additional recogni'ed bene!its o! clinical path$ays that include cost e!!ectiveness and access to patient status reports. #I/" 0ognitive 1evel" *pplication 34/" .age D5 4valuation 8,0" +0149" ,a!e and 4!!ective 0are 4nvironment T7." +ursing .rocess"

1A. * nurse sho$s the best understanding o! the legal importance o! the patients chart $hen stating" a Jou al$ays document in ink and never erase or use $hite out in the nursing . notes. b Its a document that sho$s proo! that the patient received care that met the . e pected standards. c .atient charts are care!ully protected !rom unla$!ul access by inappropriate . individuals or institutions. d The patient has a legal right to the in!ormation contained in the chart but not the . original documentation itsel!.

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*+," The patients chart is a legal document that e!!ectively communicates patient outcomes, medications, treatments, responses, and unusual incidents re!lecting the healthcare systems attempts at meet the standard o! care appropriate !or this patient. The other options are not as inclusive in describing the legal status o! the chart. #I/" 0ognitive 1evel" *pplication 34/" .age DE T7." +ursing .rocess" ImplementationK ;Teaching and 1earning< 8,0" +0149" ,a!e and 4!!ective 0are 4nvironment 15. The nurse best !ul!ills the obligation to be accountable !or providing care that meets the e pected standards o! care $hen" a #eveloping a therapeutic relations $ith the patient . b *pplying evidence%based nursing practice to the plan o! care . c .roviding appropriate discharge planning to meet the patients needs . d 4valuating the e!!ectiveness o! interventions through achievement o! outcomes . *+," # 4valuation o! the patients progress and the nursing activities involved are critical because nurses are accountable !or the standards o! care in each discipline. *lthough the other options re!lect appropriate and e pected nursing interventions, they are not the primary means o! assuring that standard o! care has been met. #I/" 0ognitive 1evel" *pplication 34/" .age DE .lanning 8,0" +0149" ,a!e and 4!!ective 0are 4nvironment T7." +ursing .rocess"

1D. The nurse assesses a patients )udgment by asking" a HWhy did you run a$ay?H . b HWhen did you !irst start hearing voices?H . c What $ould you do i! you smelled smoke in your home? . d H#o you believe you hear voices, or do you think it is in your mind?H . *+," 0

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Ludgment is the ability to assess and evaluate situations, make rational decisions, understand conse(uences o! behavior, and take responsibility !or actions. Ludgment may be assessed by asking a (uestion that has a common%sense ans$er. The other options ask about motivation, elicits historical in!ormation about the illness or seeks in!ormation about insight. #I/" 0ognitive 1evel" *pplication 34/" .age 5A T7." +ursing .rocess" Implementation 8,0" +0149" ,a!e and 4!!ective 0are 4nvironmentK .sychological Integrity 1E. The nurse responsible !or the care plan o! a patient diagnosed $ith cognitive impairment includes rationales !or the nursing interventions primarily to" a .rovide a means !or outcome evaluation . b *ccount !or the reasoning that drives the nursing action . c ,upport the patients success in achieving the e pected outcome . d .rovide in!ormation to aide in the implementation o! the nursing action . *+," 3ationales primarily re!lect nurses accountability !or their actions by e plaining $hy the action is necessary and e pected to positively impact the patients condition. 3ationales are not used to support or evaluate the success o! the intervention nor to educate ho$ the action should be pre!ormed. #I/" 0ognitive 1evel" *pplication 34/" .age DE .lanning 8,0" +0149" ,a!e and 4!!ective 0are 4nvironment T7." +ursing .rocess"

1@. * patient $ho has a nursing diagnosis o! ine!!ective coping related to ine!!ective problem solving has been involved in treatment !or E months. The nurse determines that the planned interventions re(uire revision $hen the patient states" a I really dont think my psychiatrist actually helps me. . b I cant decide i! I should get my o$n apartment or not. . c I cant accept that I $ill never be able to com!ortably make decisions. . d I dont think Im liked $ell enough to seek election as a committee . chairperson. *+," -

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+ursing interventions describe a speci!ic course o! action or a therapeutic activity that helps the patient to move to$ard a more !unctional stateK in this case problem solving. The statement indicates indecision and suggests that problem solving is still a patient problem. ,ho$ing dislike o! the physician actually sho$s a decision. +ot accepting the reali'ation o! ine!!ective decision making is not related to ine!!ective coping but rather sho$s !ocus on a!!ecting the problem. 4 pressing the perception that one is not liked concerns sel!%esteem. #I/" 0ognitive 1evel" *pplication 34/" .age D5 T7." +ursing .rocess" 4valuation 8,0" +0149" ,a!e and 4!!ective 0are 4nvironmentK .sychological Integrity 1B. To best !acilitate interdisciplinary communication regarding the plan o! care !or a patient diagnosed $ith paranoid schi'ophrenia, the nurse" a 3e(uires $eekly meetings o! the care team . b 4nsures the team includes members !rom all appropriate disciplines . c &ses the standardi'ed +I0 classi!ication system o! care interventions . d 3ecogni'es the need !or team access to patient records and makes them available . *+," 0 The +ursing Interventions 0lassi!ication ;+I0< is the !irst comprehensive standardi'ed classi!ication o! interventions. The +I0 states that one should not change intervention labels and de!initions so that there is no con!usion across settings. *lthough not inappropriate, the remaining options do not directly minimi'e con!usion related to communication. #I/" 0ognitive 1evel" *pplication 34/" .age DD T7." +ursing .rocess" Implementation 8,0" +0149" ,a!e and 4!!ective 0are 4nvironment 1C. When revie$ing the history o! a ne$ly admitted patient diagnosed $ith severe chronic depression, the nurse is most concerned about patient sa!ety issues $hen noting" a The patients * is II includes a diagnosis o! mental retardation . b #ocumentation that the patient has been noncompliant regarding medications . c The patients current Ilobal *ssessment o! /unctioning ;I*/< ,cale rating is C . d 3e!erence to a recent physical in)ury resulting !rom the patients impulsive . behavior *+," 0

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The Ilobal *ssessment o! /unctioning ;I*/< ,cale is one o! the tools use to assess patient !unctioning and possible prognosis. It is coded on a numerical continuum, $ith 1 indicating little danger and 16 indicating severe or persistent danger, and possible suicidal potential. 8ental de!iciency may contribute to issues o! sa!ety but it is not a signi!icant risk !actor. +oncompliance may contribute to the patients depression but it is not the greatest concern identi!ied. *lthough past history is considered a predictor o! !uture behavior, this is more related to the sa!ety o! others than to the patient. #I/" 0ognitive 1evel" *pplication 34/" .age 5C T7." +ursing .rocess" *ssessment 8,0" +0149" ,a!e and 4!!ective 0are 4nvironmentK .sychological Integrity :6. *n appropriate nursing diagnosis !or a patient $ho mani!ests a psychological problem through !re(uent e pressions o! un!ounded or e cessive guilt or shame, states that he is unable to deal $ith situations, and has a hesitation to try ne$ things $ould be" a Gopelessness . b .o$erlessness . c Ine!!ective coping . d 0hronic lo$ sel!%esteem . *+," # The behaviors mentioned in the situation are congruent $ith criteria !or the diagnosis o! chronic lo$ sel!%esteem. The patients symptoms go beyond po$erlessness. Gopelessness does not involve !eelings o! guilt and shame. The data is not consistent $ith a diagnosis o! ine!!ective coping. #I/" 0ognitive 1evel" *pplication 34/" .age 5@ T7." +ursing .rocess" *nalysis 8,0" +0149" ,a!e and 4!!ective 0are 4nvironmentK .sychological Integrity :1. * $ell%stated outcome criteria !or a patient $ith a nursing diagnosis o! risk !or loneliness related to social isolation $ould include The patient $ill" a +o longer e perience loneliness by the end o! the !i!th day o! hospitali'ation. . b *gree to attend t$o on%unit, sta!!%directed group sessions daily. . c 0ontinue to maintain social solitude D6M o! the time. . d Interact $ith a peer on a daily basis by discharge. . *+," #

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7utcome criteria !or a risk diagnosis are developed !rom the risk !actorsNin this case, social isolation. 7utcomes meet criteria $hen they are measurable, speci!ic, and present a timeline !or completion. The correct option meets all criteria. There is no stated means by $hich to measure loneliness. *greeing to attend is not speci!ically directed at a!!ecting social isolation since interaction is not an e pectation. ,ocial solitude promotes social isolation. #I/" 0ognitive 1evel" *pplication 34/" .age 5C T7." +ursing .rocess" .lanning 8,0" +0149" ,a!e and 4!!ective 0are 4nvironmentK .sychological Integrity ::. 0are planning !or a patient diagnosed $ith paranoid schi'ophrenia $ill include" a *naly'ing e!!ectiveness o! care provided . b #etermining the patients needs and problems . c 4stablishing realistic patient%!ocused outcome criteria . d Identi!ying priorities o! care based on the patients condition . *+," # 4stablishing priority nursing diagnoses is part o! the process o! planning. #etermining needs is part o! assessment. *naly'ing e!!ectiveness is an evaluation activity. 4stablishing realistic e pectations is part o! outcome identi!ication. #I/" 0ognitive 1evel" *pplication 34/" .age D1 .lanning 8,0" +0149" ,a!e and 4!!ective 0are 4nvironment T7." +ursing .rocess"

:A. The e pert nurse is con!ident that the novice nurse understands the principles that guide the planning o! patient care interventions $hen the" a +ovice nurse asks the patient to identi!y their primary concerns . b .atient success!ully achieves the agreed upon nursing outcomes . c 4 pert nurse re(uests that the novice nurse observe several care planning sessions . d +ovice nurse includes interventions that are supported by evidence%based . practices *+," * Working $ith the patient to determine treatment priorities is a characteristic o! good care planning. *lthough success!ul achievement o! e pected outcomes and inclusion o! 4-. interventions re!lect appropriate care planning, such success is in!luenced by many di!!erent !actors. *lthough appropriate, observing care planning sessions does not necessarily a!!ect success!ul care planning on the part o! the novice nurse.

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