Chapter 1 Flashcards
(17 cards)
A patient with a history of an anxiety disorder is brought to the emergency department by their spouse, who tells the nurse the patient is having a panic attack. Which strategy can the nurse use to make collecting the patient history data more tolerable for the patient?
Review the record for a history of similar episodes in the past.
Stop asking questions of the patient until they have calmed down.
Repeat the questions until the patient is able to provide a response.
Avoid asking questions of the patient and gather assessment data from the spouse.
Review the record for a history of similar episodes in the past.
(Knowing the patient’s history, including previous episodes and treatment, allows the nurse to ask only critical questions and not exhaust the patient with questions that the nurse can find the answers to in the medical record.)
Which explanation would the nursing instructor provide to students regarding why the six-step nursing process approach is used in mental health nursing?
The process is ingrained in nursing history and is important to maintain.
Following this process is mandatory according to the state nurse practice act (NPA).
The nurse is able to make judgements and choose behaviors relevant to individual patient care.
The six steps allow the nurse to better understand the patient’s medical or mental health diagnosis.
The nurse is able to make judgements and choose behaviors relevant to individual patient care.
(Use of the six steps of the nursing process allows the nurse to identify individual patient problems and select appropriate patient goals and the interventions necessary to achieve those goals. Following evaluation of the progress toward, or achievement of, the outcomes and goals, the process starts again and remains ongoing. This logical framework allows the nurse to make judgements and revisions to the patient’s plan of care.)
Which aspect of the patient outcome “Mr. X will report his pain at a 2 or below on a 0-10 pain scale” is missing?
A reliable measuring tool
A description of what is being measured
A time by which the outcome will be achieved
An indication of what will change for the patient
A time by which the outcome will be achieved
(The time by which the patient is expected to achieve the outcome is missing. An example, in this case, might be “by discharge.”)
The nurse’s plan for a patient who presents with a mental health concern is appropriate if the interventions have which characteristic?
Chosen by the patient
Conform to a standardized plan of care
Attainable and acceptable by both patient and nurse
Similar to what has been done in the past for patients with the same concerns
Attainable and acceptable by both patient and nurse
(A plan that is based on interventions that are attainable and acceptable to both nurse and patient is appropriate and the most likely to result in positive patient outcomes.)
The nurse evaluates the patient’s response to care and notes improvement regarding an acute mental health concern. Which activity should follow?
The patient is discharged from care.
The plan remains unchanged because the patient may regress.
The plan shifts focus to prevention and health-promotion efforts.
The patient assumes responsibility for determining appropriate changes in care.
The plan shifts focus to prevention and health-promotion efforts.
(As an acute situation resolves, the plan of care can shift focus to prevention and health-promotion strategies, with the goal being that the acute concern does not recur.)
Which statement made by a nursing student regarding documentation of health information indicates that the student requires further teaching?
“Documentation is an important aspect of communication but is unrelated to how the health care facility is reimbursed for services.”
“All components of the patient’s medical record are considered part of a legal document.”
“Use of an electronic medical record reduces the burden of documentation.”
“All documents signed by the patient in the course of care are part of the medical record.”
“Documentation is an important aspect of communication but is unrelated to how the health care facility is reimbursed for services.”
(The statement that documentation is unrelated to reimbursement requires further teaching because government-mandated requirements now tie payment to contents and methods of documentation within the medical record.)
Which characteristic of the patient with a mental health concern poses a challenge for the nurse while collecting assessment data?
The patient will often not admit to experiencing a problem.
The patient and family want the same thing from the nurse.
The patient often refuses to speak with the nurse, preferring a therapist instead.
A frightened patient will often shut down and the nurse will not be able to communicate effectively.
The patient will often not admit to experiencing a problem.
(An aspect of psychiatric illness can often be the patient’s inability to see their own symptoms or disease. Therefore it can be challenging for the nurse to collect meaningful historical assessment data.)
Which statement explains the benefit of the nursing diagnosis when used in the care of a patient with a mental health concern?
This step helps any nurse to understand the patient’s problem.
Having a nursing diagnosis postpones the need to establish a medical diagnosis.
A nursing diagnosis is required for the insurer to reimburse health care delivery system.
Labeling the patient problem with a nursing diagnosis eliminates the need to collect a patient history.
This step helps any nurse to understand the patient’s problem.
(Because the nursing diagnosis is selected from a standardized classification system, a shared understanding of the patient’s problem(s) is established among nurses who may be providing care to the patient at different times.)
Which explanation would the nursing instructor provide to students regarding the rationale for using a standardized psychosocial interviewing tool, such as HEADSSS (Home, Education/Employment, Activities, Drugs, Sexuality, Suicide)?
Use of the tool ensures that all important aspects of patient data are accounted for.
Use of a standardized interviewing tool allows the nurse to collect assessment data once during patient care.
The tool is embedded in all electronic medical records (EMRs) as a standard component of patient documentation.
Use of a standardized interview tool is mandated by the Psychiatric Mental Health Nursing Scope and Standards of Practice.
Use of the tool ensures that all important aspects of patient data are accounted for.
(Repeated use of a standardized mnemonic helps the nurse consistently collect the most pertinent aspects of patient data at each encounter.)
Which statement explains the role of safety in planning care for a patient with an acute mental health concern?
Addressing the acute mental health crisis is the first priority in patient care.
The acute mental health issue is not addressed until the health care team and patient are safe.
The severity of the mental health concern determines which aspect of care is given priority.
Assessing and treating the acute mental health concern is prioritized before other physical concerns.
The acute mental health issue is not addressed until the health care team and patient are safe.
(Only after the patient’s immediate life-sustaining physical needs are met and a safe environment is ensured will the mental health concern be addressed in the plan of care.)
The nursing intervention classification (NIC) system provides which benefit to the nurse planning for and intervening on behalf of a patient with a mental health concern?
Minimizing the need for ongoing patient assessment
Helping the nurse to select the most appropriate nursing diagnosis
Improving quality of care through the use of standardized interventions
Helping the nurse to select patient outcomes related to the nursing diagnosis
Improving quality of care through the use of standardized interventions.
(NIC is evidence-based, so use of these interventions helps to ensure that quality care is delivered.)
Which interventions by the nurse demonstrate an understanding of the importance of the therapeutic relationship when working to achieve agreed upon patient outcomes?
Select all that apply.
Asking the patient how important it is to them to feel better
Telling the patient that things are not as bad as they seem
Sitting quietly with the patient when they have had a bad day
Advising the patient regarding which treatment options would be best for them
Filling in silences with social conversation to make the patient feel comfortable
Role playing with the patient in preparation for a challenging conversation with family
Asking the patient how important it is to them to feel better.
Sitting quietly with the patient when they have had a bad day.
Role playing with the patient in preparation for a challenging conversation with family.
Which actions taken by the nurse demonstrate implementation of the plan of care for the patient with a mental health concern?
Select all that apply.
Practicing relaxation breathing with the patient
Administering ordered doses of antidepressant medication
Helping the patient connect with an outpatient support group
Updating the patient record with information about response to group therapy
Questioning the patient about mental health symptoms 2 weeks after starting a new medication
Providing positive reinforcement to a patient who eats breakfast in the common area with other
Practicing relaxation breathing with the patient.
Administering ordered doses of antidepressant medication.
Helping the patient connect with an outpatient support group.
Providing positive reinforcement to a patient who eats breakfast in the common area with other patients.
Which rationale would the nursing instructor provide when discussing the need to evaluate the plan of care?
Evaluation will help the nurse select a discharge-from-care date.
This step is necessary to determine if the patient is progressing toward their goals.
This step supports the initial goals that were set and offers validity for leaving them unchanged.
Evaluating the plan of care allows the nurse to minimize documentation and move on to other patient problems.
This step is necessary to determine if the patient is progressing toward their goals.
(The six-step nursing process is circular in nature. Evaluation is necessary to determine if a patient is making progress toward established goals. If not, the process has to start again, so the goals can be reset and interventions revised if needed.)
Which situations would the nurse need to document in the health record of a patient with a mental health concern?
Select all that apply.
Medication for anxiety is administered as ordered.
A patient used their personal phone throughout the day.
A patient with an anxiety disorder sleeps through the night.
The hospitalized patient has an uneventful visit from family.
The nurse hears a patient tell their visitor of plans to leave the facility that evening.
The nurse provides a patient with information about rules for participation in group therapy.
Medication for anxiety is administered as ordered.
A patient with an anxiety disorder sleeps through the night.
The nurse hears a patient tell their visitor of plans to leave the facility that evening.
The nurse provides a patient with information about rules for participation in group therapy.
Which examples of acceptable patient “charting” would the nursing instructor include in a lab activity on documentation?
Select all that apply.
“I talked to my patient earlier about how he was feeling.”
“The patient was noncompliant today, refusing to attend group therapy.”
“Routine medication administered this morning at 0800. Patient tolerated without difficulty.”
“Symptoms of anxiety were observed, including restlessness, agitation, and pressured speech.”
“The patient actively participated in group therapy today, offering several insights and listening to others.”
“Routine medication administered this morning at 0800. Patient tolerated without difficulty.”
“Symptoms of anxiety were observed, including restlessness, agitation, and pressured speech.”
“The patient actively participated in group therapy today, offering several insights and listening to others.”
At which point in patient care would the nurse complete the evaluation step of the nursing process?
On the day of discharge
At predetermined times throughout patient care
When the health care provider requests it be done
When the patient states that they no longer require treatment
At predetermined times throughout patient care.
(The nurse evaluates patient progress at set intervals to determine if the plan of care is appropriate, if the patient is making progress toward the goals of treatment, or if the plan needs to be revised.)
