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Varcarolis: Chapter 7 - The Nursing Process and Standards of Care for Psychiatric Mental Health Nursing 100% verified
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Varcarolis: Chapter 7 - The Nursing Process and Standards of Care for Psychiatric Mental Health Nursing 100% verified

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  • November 15, 2023
  • 11
  • 2023/2024
  • Exam (elaborations)
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Subjects

  • a patient diag
  • psychiatric mental health nursing
  • a new staff nurse completes an orientation to the
  • a newly admitted patient diagnosed with major depr
  • risk for suicide is the priority diagnosis when th

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Varcarolis:
Chapter
7
-
The
Nursing
Process
and
Standards
of
Care
for
Psychiatric
Mental
Health
Nursing
A
new
staff
nurse
completes
an
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.
Prescribe
psychotropic
medication.
c.
Establish
therapeutic
relationships.
d.
Individualize
nursing
care
plans.
-
ANSANS:
B
Prescriptive
privileges
are
granted
to
master's-prepared
nurse
practitioners
who
have
taken
special
courses
on
prescribing
medication.
The
nurse
prepared
at
the
basic
level
performs
mental
health
assessments,
establishes
relationships,
and
provides
individualized
care
planning.
Note
that
this
question
was
also
offered
for
Chapter
1.
A
newly
admitted
patient
diagnosed
with
major
depression
has
gained
20
pounds
over
a
few
months
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:
more
than
body
requirements
b.
Chronic
low
self-esteem
c.
Risk
for
suicide
d.
Hopelessness
-
ANSANS:
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
would
a
suicide
attempt.
A
patient
diagnosed
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
has
the
highest
priority?
a.
Implement
suicide
precautions.
b.
Offer
high-calorie
snacks
and
fluids
frequently.
c.
Assist
the
patient
to
identify
three
personal
strengths.
d.
Observe
patient
for
therapeutic
effects
of
antidepressant
medication.
-
ANSANS:
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.
The
desired
outcome
for
a
patient
experiencing
insomnia
is,
"Patient
will
sleep
for
a
minimum
of
5
hours
nightly
within
7
days."
At
the
end
of
7
days,
review
of
sleep
data
shows
the
patient
sleeps
an
average
of
4
hours
nightly
and
takes
a
2-hour
afternoon
nap.
The
nurse
will
document
the
outcome
as:
a.
consistently
demonstrated. b.
often
demonstrated.
c.
sometimes
demonstrated.
d.
never
demonstrated.
-
ANSANS:
D
Although
the
patient
is
sleeping
6
hours
daily,
the
total
is
not
one
uninterrupted
session
at
night.
Therefore,
the
outcome
must
be
evaluated
as
never
demonstrated.
See
relationship
to
audience
response
question.
The
desired
outcome
for
a
patient
experiencing
insomnia
is,
"Patient
will
sleep
for
a
minimum
of
5
hours
nightly
within
7
days."
At
the
end
of
7
days,
review
of
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.
Examine
interventions
for
possible
revision
of
the
target
date.
-
ANSANS:
D
Sleeping
a
total
of
5
hours
at
night
remains
a
reasonable
outcome.
Extending
the
period
for
attaining
the
outcome
may
be
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.
Removing
this
nursing
diagnosis
from
the
plan
of
care
would
be
correct
when
the
outcome
was
met
and
the
problem
resolved.
Writing
a
new
nursing
diagnosis
is
inappropriate
because
no
other
nursing
diagnosis
relates
to
the
problem.
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.
Implementation
d.
Evaluation
-
ANSANS:
C
Interventions
are
the
nursing
prescriptions
to
achieve
the
outcomes.
Interventions
should
be
specific.
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.
-
ANSANS:
B
Assessment
should
include
data
obtained
from
both
the
primary
and
reliable
secondary
sources.
The
nurse,
bearing
in
mind
the
possible
effects
of
counter-transference,
should
evaluate
biased
assessments
by
others
as
objectively
as
possible.
A
patient
presents
to
the
emergency
department
with
mixed
psychiatric
symptoms.
The
admission
nurse
suspects
the
symptoms
may
be
the
result
of
a
medical
problem.
Lab
results

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