Varcarolis: Chapter 7 - The Nursing Process And St
Varcarolis: Chapter 7 - The Nursing Process and St
Exam (elaborations)
Varcarolis: Chapter 7 - The Nursing Process and Standards of Care for Psychiatric Mental Health Nursing
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Course
Varcarolis: Chapter 7 - The Nursing Process and St
Institution
Varcarolis: Chapter 7 - The Nursing Process And St
Varcarolis: Chapter 7 - The Nursing Process and Standards of Care
for Psychiatric Mental Health Nursing
Question 1:
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...
Varcarolis: Chapter 7 - The Nursing Process and Standards of Care
for Psychiatric Mental Health Nursing
Question 1:
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.
Answer: b. Prescribe psychotropic medication.
Feedback: Advanced practice nurses, such as nurse practitioners, have prescriptive privileges and the
ability to prescribe medications after receiving additional training, while basic nursing roles do not
include this privilege.
---
Question 2:
A newly admitted patient diagnosed with major depression has gained 20 pounds over a few months
and has suicidal ideation. The patient has taken 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
Answer: c. Risk for suicide
Feedback: Given the presence of suicidal ideation, the priority nursing diagnosis must focus on patient
safety to address immediate risks.
,---
Question 3:
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 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.
Answer: a. Implement suicide precautions.
Feedback: Ensuring patient safety through suicide precautions is the highest priority when there is an
active plan for suicide, as it directly addresses immediate danger.
---
Question 4:
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.
Answer: d. never demonstrated.
Feedback: Since the patient did not meet the minimum requirement of 5 uninterrupted hours of sleep at
night, this outcome is evaluated as "never demonstrated."
---
, Question 5:
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, the 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.
Answer: d. Examine interventions for possible revision of the target date.
Feedback: Extending the timeline for achieving the sleep goal while also considering modifications to
interventions is a sensible next step in managing the patient's care.
---
Question 6:
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
Answer: c. Implementation
Feedback: Interventions such as encouraging attendance at psychoeducational groups are recorded
under the implementation section, where specific actions to achieve patient goals are documented.
---
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