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A nurse is assisting with the development of a plan of care for a client diagnosed with schizophrenia who is actively hallucinating. Which outcome would be appropriate for a long-term time frame?
A. Client does not harm self in the next 48 hours.
B. Client reports a decrease in anxiety level within 24 hours.
C. Client identifies factors that precipitate hallucinations by discharge.
D. Client identifies feelings associated with hallucinations with each episode.
Answer: C
Rationale: An outcome for a long-term time frame would include that the client identifies factors that precipitate hallucinations by discharge. The other options would be considered more short-term in terms of time frame, because they address 24 hours, 48 hours and each episode rather than by the time of discharge.
A nurse is engaged in different interventions. Which intervention directly demonstrates the effectiveness of the delivery of nursing care?
A. Assessing a client newly admitted for evaluation of cognitive function
B. Identifying risk for injury as a priority nursing care focus for a client who is suicidal
C. Reassessing the client to update the current plan of care
D. Planning interventions that support the client's need for safety
Answer: C
Rationale: The evaluation phase is a form of validation for the entire nursing process in the delivery of care to the client. Continued data collection may indicate new problems or alterations in the original nursing care focuses. Outcomes are clarified to reflect realistic and measurable terms for the client. Nursing interventions are reevaluated for effectiveness. Continued data collection and revisiting the plan of care allow the nurse a system of addressing client problems in the most effective manner toward resolution. While important, the other options fail to demonstrate the effectiveness of the care being given.
A nurse is conducting a psychosocial assessment on a client diagnosed with depression. When documenting observations related to the client’s mood, which term would the nurse likely use?
A. Blunted
B. Flat
C. Euphoric
D. Inarticulate
Answer: C
Rationale: A client's mood may be described as euphoric, labile, and fearful. Blunted and flat are terms used to describe observations of the client's affect. Being inarticulate is not specifically related to mood.
A client has been admitted to an inpatient mental health unit following a suicide attempt. Which nursing care focus statement would be considered a priority for this client?
A. Ineffective individual coping related to life events
B. Increased risk for self-injury related to past history
C. Altered nutrition, less than body requirements, related to depression
D. Body image disturbance related to scar on wrist
Answer: B
Rationale: Any health condition that endangers life will receive a high priority. Situations that are recurrent or chronic may be given a lower priority and will be addressed at a later time. A client with suicidal ideation or intent, or history of such an attempt, for example, would have an immediate risk for self-injury. While the remaining options identify possible appropriate nursing care focus statements the priority in this situation is the risk of future self-harm.
A nurse is documenting subjective data about a client diagnosed with chronic depression. Which statement would reflect the most descriptive and accurate documentation about the client?
A. Client's state of depression reflected by refusal to attend the unit's current affairs group.
B. Client states, “I can't remember a time when I wasn't depressed and able to really enjoy my life.”
C. Client's journal contains numerous entries devoted to the description of personal state of depression.
D. Client's adult child states, “We have a long history of depression among the members of my dad's family.”
Answer: B
Rationale: When collecting subjective data, it is important for the nurse to be as accurate and descriptive as possible. Citing direct quotes from the client is a way of including what the client is saying without attempting to interpret the intended meaning. Using the client's own words to describe feelings or thoughts often provides insight into perceptual distortions or illogical thought processes. While the other options show methods of documenting sources of subjective information, they lack the qualities preserved by citing a direct client quote.
The nurse is reviewing the plan of care for a client diagnosed with bipolar disorder. The nurse is working on ways to help the client rechannel the client's energies in a constructive manner. The nurse is most likely involved in which component of the nursing process?
A. Assessment
B. Nursing care focus
C. Implementation
D. Evaluation
Answer: C
Rationale: Nursing interventions are intended to encourage, maintain, and re-establish a level of mental and physical functioning that promotes the client's well-being through the achievement of anticipated outcomes. Assessment is the collection of data. Nursing care focus (nursing diagnosis) is an identification of a client problem based on conclusions about collected data. During the evaluation phase of the nursing process, the nurse evaluates the success of the nursing interventions in meeting the criteria outlined in the expected outcome.
After conducting a mental health assessment on a client diagnosed with schizophrenia, the nurse participates in a team planning meeting. When reporting assessment findings to the team related to the client’s affect, which term would the nurse likely use?
A. Apathetic
B. Suspicious
C. Blunted
D. Hostile
Answer: C
Rationale: A client's affect can be blunted. Apathetic, suspicious, and hostile are all descriptive terms for attitude.
The nurse is creating a plan of care for a client diagnosed with a chronic mental illness. The nurse integrates understanding of outcome achievement for client-focused interventions based on which statement?
A. “Your mental health care team has extensive experience working with clients who have chronic mental health diagnoses like yours.”
B. “I'd like to spend this time together to provide you with important information regarding your newly prescribed antidepressant.”
C. “The management of a chronic mental illness requires cooperation and collaboration between you the client, and your mental health care team.”
D. “I value your opinions and suggestions concerning your treatment plan since it must be adapted to your personal needs in order to be successful.”
Answer: D
Rationale: The care plan's goals and outcomes should be determined in collaboration with the client, so as to increase cooperation and compliance with therapeutic interventions. While knowledge, whether it is about medication therapy or the health care team's degree of experience, is reassuring to some clients, it is not associated with increasing client compliance. It is true that the management of a chronic illness does require cooperation and collaboration but these factors are more likely to exist when the client has an active role in the planning of their care.
When ensuring the therapeutic milieu, which aspect is considered a vital component?
A. Dependency
B. Biofeedback
C. Consistency
D. Electroconvulsive therapy
Answer: C
Rationale: Consistency is a vital component of the therapeutic milieu. Dependency, biofeedback, and electroconvulsive therapy are not components of the therapeutic milieu.
A nurse is talking with a client who was just admitted to the mental health unit. The nurse integrates understanding of the need for a therapeutic milieu based on which statement to the client?
A. “The staff is dedicated to making this unit's environment therapeutic.”
B. “This is a safe place for you to express your feelings without concern about how you will be accepted.”
C. “I want you to understand that our focus is to help you get better, and we’ll do whatever it takes to make that happen.”
D. “You have a role to play in making the unit a therapeutic environment.”
Answer: B
Rationale: The unit's environment is therapeutic when it is modified to create a setting in which the client feels safe, secure, and free to express feelings and thoughts without fear of rejection, retaliation, or punishment. The nurse can best build a relationship and establish a sense of trust by approaching the client in an accepting and nonjudgmental manner. While staff strives to support a client, it is not therapeutic to promise recovery. It is the staff's responsibility not the client's to provide a therapeutic milieu. The statement about staff's dedication does not provide an example of what is involved in making the environment therapeutic.
A nurse is gathering information from a client new to the mental health center. The nurse collects subjective data by asking which question?
A. “When did you begin taking your antianxiety medication?”
B. “What types of events cause you to feel anxious?”
C. “Is there a history of chronic anxiety in your family?”
D. “Has your anxiety affected your blood pressure?”
Answer: B
Rationale: Subjective data are provided by the client and typically include the client's history and perception of the present situation or problem, in addition to feelings, thoughts, symptoms, or emotions that they may be experiencing such as identifying events that are anxiety producing. The remaining questions are directed at gathering objective data such as concrete dates, events, and medical history.
A nurse is providing care to several clients. Which concept would the nurse apply when prioritizing the clients’ needs?
A. Client's current problems have priority over those problems that may develop.
B. Client's psychiatric diagnosis dictates the priority of nursing interventions.
C. Physiologic problems have priority over psychosocial problems.
D. Client's perception of their problems determines the priority.
Answer: A
Rationale: It is important to give priority to the problem that the client is currently experiencing (actual) over a problem that may happen (potential). It is the nature of the problem, not the psychiatric diagnosis that determines priority. It is not always true that physiologic problems have priority over psychosocial ones, for example, a suicidal ideation would have priority over a minor medical problem. While the perceptions of the client are considered, the prioritizing of needs is based on nursing judgment.
A nurse demonstrates understanding of planning client-focused and client-driven interventions based on which statement?
A. “All clients are required to do their own laundry using the unit's washer and dryer.”
B. “It is necessary that each newly admitted client be able to restate unit rules.”
C. “Clients who are capable of bathing themselves will do so three times a week.”
D. “Suicidal clients will be contracted for safety at the beginning of each shift.”
Answer: C
Rationale: It is important to plan actions that are appropriate for the individual client and take into consideration the level of functioning that is realistic for that person. What may be realistic for one person may be unattainable for another as in the case of performing self-hygiene care. All clients may not be capable of attending to their own laundry or have the capacity to comprehend or restate unit rules at the time of their admission. Monitoring suicidal clients is a nursing-focused intervention.
A nurse who has assisted with the development of the plan of care for a client admitted with a diagnosis of acute situational depression, is now engaged in the evaluation phase. With which activity would the nurse be involved?
A. Revising the client's plan of care to include daily behavioral therapy sessions
B. Conducting a mini mental health assessment on admission
C. Supporting the client's efforts to identify the event that triggered the depression
D. Educating the client on the expected effects of a newly prescribed antidepressant
Answer: A
Rationale: The evaluation phase is a form of validation for the entire nursing process in the delivery of care to the client. Continued data collection and revisiting the plan of care allow the nurse a system of addressing client problems in the most effective manner toward resolution. An assessment such as the mini mental health screening is considered a component of the assessment phase of the nursing process. Supporting and educating the client are interventions associated with the implementation of the plan of care.
The outcomes for a client with acute depression have been partially met. Which question(s) should the nurse ask to maximize the overall success of the client's treatment plan? Select all that apply.
A. “Is the outcome one that the client can realistically achieve?”
B. “Should the timetable for goal achievement be extended?”
C. “Is the client motivated sufficiently to achieve the goal?”
D. “Which interventions, if any, have proven to be ineffective?”
E. “Is the client capable of achieving any therapeutic goal?”
Answer: A, B, C, D
Rationale: If a goal has been partially met, there may be supporting data to indicate continuance of the current plan of care. This approach recognizes that the client may need more time to make changes and adjust to them. A distinction must be made between a lack of client motivation and the need for continuance of the current plan to help the client achieve the outcomes. Some interventions may have been ineffective, and thus new strategies may be needed to help meet the client's needs. It is also important to reevaluate the outcome criteria; the expected outcome may not actually be achievable for this client. All clients are capable of achieving goals. The success is determined by the selection and design of goals that are achievable for the specific client.
The nurse is reviewing the nursing care focus statements identified for a client diagnosed with major depression. Which information would the nurse expect to see included? Select all that apply.
A. Actual or potential problem related to the client's problem
B. Causative or contributing factors
C. Nursing interventions specific to the client
D. Behavior or symptoms that support the problem
E. Methods to evaluate client progress
Answer: A, B, D
Rationale: Formulating a nursing care focus statement (nursing diagnosis) consists of three parts: (1) the actual or potential problem related to the client's condition, (2) the causative or contributing factors, and (3) a behavior or symptom that supports the problem. The nursing care focus statement (nursing diagnosis) does not consist of nursing intervention or evaluation methods specific to the client.
The nurse is completing a psychosocial assessment. Which information would the nurse document as objective data gathered during a client's psychosocial assessment? Select all that apply.
A. Relationship problems
B. Motor activities
C. Affect
D. Awareness
E. Speech patterns
Answer: B, C, D, E
Rationale: Objective data are observable and include motor activity, affect, awareness, and speech patterns. Relationship problems are considered subjective data.
The nurse is gathering data for a psychosocial assessment for a client diagnosed with an anxiety disorder. Which information would the nurse document as subjective data? Select all that apply.
A. Client's perception of the problem
B. Reports of life stressors
C. Coping strategies used
D. Relationship with family members
E. Use of prescribed antianxiety agent
Answer: A, B, C, D
Rationale: Subjective data are provided by the client and typically include the client's history and perception of the present situation or problem, in addition to feelings, thoughts, symptoms, or emotions that they may be experiencing. Medication history is considered objective data.
The nurse is documenting the psychosocial assessment data for a client diagnosed with depression. When documenting the client's motor activity, which term(s) would be appropriate for the nurse to use? Select all that apply.
A. Rigid
B. Apathetic
C. Hyperactive
D. Restless
E. Labile
Answer: A, C, D
Rationale: Terms used to describe motor activity include: pacing, slow, rigid, relaxed, restless, combative, bizarre, gait, hyperactive, retarded, aggressive. Apathetic describes attitude. Labile describes mood.
A client has been diagnosed with an anxiety disorder. When developing outcomes for this client, which outcome(s) would the nurse identify as important to achieve in the immediate time frame? Select all that apply.
A. Client reports a reduction in anxiety level within 24 hours
B. Client states the need for continued medication compliance by discharge
C. Client participates in group therapy session on day 2
D. Client reports an increased ability to concentrate within 4 hours
E. Client demonstrates positive coping methods to control anxiety in 1 week.
Answer: A, C, D
Rationale: In the immediate time frame, appropriate outcomes would include a reduction in anxiety level, participation in group therapy and an increased ability to concentrate. These are more short-term outcomes geared to the immediate situation. The outcomes related to medication compliance and positive coping, although appropriate, are more long term in nature, which is in 1 week and by discharge.