Nursing Process in PMN Exam Study With Practice Questions And Answers.

ASSESSMENT: INFLUENCING FACTORS & CONSIDERATIONS - correct answer -Client's ability & willingness to participate -Health status & physical considerations -Previous experiences with health care providers & settings -Client's ability to understand -Age & Language Barriers -Nurse's attitude and approach -Environment ASSESSMENT CONSIDERATIONS: Medical Conditions With Behavioral/Psych Symptoms - correct answer Thyroid disorders Anemia Coronary conditions Asthma Lupus Diabetes Electrolyte imbalances Mitral valve prolapse Parkinson's Disease Stroke Chronic Pain Syndrome Medication adverse effects Cancer Multiple sclerosis AIDS COPD MEDICAL MIMICKS mnemonic: "THINCMED" - correct answer T = Tumors H = Hormones I = Infection/Autoimmune N = Nutrition C = Central Nervous System M = Miscellaneous E = Electrolytes D = Drugs/Toxins ASSESSMENT GOALS - correct answer Gain an understanding of the current problem Review physical status & baseline vitals Assess safety risks: suicide/homicide Complete mental status exam (MSE) Complete a psychosocial assessment Identify goals for treatment Formulate a plan of care, prioritizing immediate needs GATHERING DATA - correct answer ALWAYS RULE OUT PHYSIOLOGICAL CAUSE -Laboratory data & diagnostic studies when warranted History of present illness LET THE PATIENT TELL THEIR STORY Mental status exam (MSE) Psychosocial assessment Validate/verify assessment Use rating scales Remember all behavior has meaning ASSESSMENT PRIORITY: SAFETY - correct answer Assess Risk for Violence (Toward Self or Others) -BE DIRECT ASSESS: Ideation Intent Plan Means Past history -MANAGE immediate safety concerns ASSESSMENT CONTENT - correct answer History of present illness: Onset and Severity if chronic "why now?" Impact on ability to function & relationships Developmental stage actual versus functional Cultural considerations Spiritual beliefs Previous history Mental Status Exam The mnemonic ASEPTIC can be used to remember the components of the Mental Status Examination - correct answer A - Appearance/Behavior S - Speech E - Emotion (Mood and Affect) P - Perception (Auditory/Visual Hallucinations) T - Thought Content (Suicidal/Homicidal Ideation) and Process I - Insight and Judgement C - Cognition assessment content: Physiological and self-care considerations - correct answer Eating habits Sleep patterns Major or chronic health problems Use of drugs and/or alcohol Noncompliance with prescribed medications assessment content: Self-concept - correct answer Personal worth and dignity Description of physical characteristics/body image assessment content: Roles and relationships - correct answer Current roles Ability to fulfill roles Changes in roles Satisfaction with relationships ADDITIONAL EVALUATION/ASSESSMENT: - correct answer Abuse/trauma Strengths & Deficits/Weaknesses Cultural & Spiritual Needs Coping Skills BIOPSYCHOSOCIAL ASSESSMENT: - correct answer Assesses current emotional state & behavioral function Basis for developing plan of care Clinical baseline to evaluate effectiveness of treatment or measure client's progress -Includes feelings, intuition and behaviors ASSESSMENT SCALES & DX TOOLS: - correct answer -Standardized tools used to monitor symptoms and cognitive function -Used throughout the treatment process to provide information regarding progress and symptom management and control THE INTERVIEW: ENVIRONMENT - correct answer Comfortable, private, safe Always know where your exit is Avoid enclosed spaces Quiet with few distractions Adhere to HIPAA requirements Sit on same level facing client GUIDELINES FOR INTERVIEWING: - correct answer Embrace recovery principles Positive regard Value the voice & validate the person "Join"/accept resistance rather than push against it Be curious, ask rather than making assumptions Make observations Demonstrate empathy Trauma informed approach LISTEN THE INTERVIEW: QUESTIONS & PACING - correct answer Open-ended to initiate assessment Focused if client cannot organize thoughts or has difficulty answering open-ended questions One question at a time Pause and allow time for response Think interview versus interrogation DATA ANALYSIS - correct answer Consider the gestalt rather than isolated bits of information -Patterns or themes in data → conclusions about clients' strengths and needs, nursing diagnoses Ongoing, dynamic process Rating tools Diagnostic studies Psychiatric diagnoses Mental status examination and mini mental status Psychosocial assessment DATA ANALYSIS: PSYCHIATRIC DIAGNOSES - correct answer Diagnostic and Statistical Manual of Mental Disorders (DSM): Classifies mental disorders into categories Describes each disorder Provides diagnostic criteria for each disorder SELF-AWARENESS ISSUES: - correct answer -Be open, clear, direct when asking about personal or uncomfortable topics. -Do not allow personal beliefs to interfere with the assessment process. -Manage biases & potential for countertransference guiding principles of recovery - correct answer holistic person-driven many pathways peer support relational/social strengths/responsibility respect culturally based addresses trauma hope PHYSICAL INTERVENTIONS: - correct answer Self Care Activity & exercise Sleep Nutrition Relaxation Hy