Nursing 126 Chapter 7 (Nursing Process and QSEN: The
Foundation for Safe and Effective Care) Questions With
Complete Solutions
A new staff nurse completes 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. Establish therapeutic relationships.
c. Prescribe psychotropic medications.
d. Individualize nursing care plans. Correct Answers c.
Prescribe psychotropic medications.
Prescriptive privileges are granted to Master's-prepared nurse
practitioners who have taken special courses on prescribing
medications. The nurse prepared at the basic level performs
mental health assessments, establishes relationships, and
provides individualized care planning.
A newly admitted patient with major depression has lost 20
pounds over the past month 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: Less than body requirements
,b. Chronic low self-esteem
c. Risk for suicide
d. Hopelessness Correct Answers c. Risk for suicide
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 a suicide attempt.
A nurse asks a patient, "If you had fever and vomiting for 3
days, what would you do?" Which aspect of the mental status
examination is the nurse assessing?
a. Behavior
b. Cognition
c. Affect and mood
d. Perceptual disturbances Correct Answers b. Cognition
Assessing cognition involves determining a patient's judgment
and decision-making capabilities. In this case, the nurse expects
a response of, "Call my doctor" if the patient's cognition and
judgment are intact. If the patient responds, "I would stop
eating" or "I would just wait and see what happened," the nurse
would conclude that judgment is impaired. The other options
refer to other aspects of the examination.
, A nurse assesses a patient who reluctantly participates in
activities, answers questions with minimal responses, and rarely
makes eye contact. What information should be included when
documenting the assessment? Select all that apply.
a. Uncooperative patient
b. Patient's subjective responses
c. Only data obtained from the patient's
verbal responses
d. Description of the patient's behavior
during the interview
e. Analysis of why the patient is
unresponsive during the interview Correct Answers b. Patient's
subjective responses
d. Description of the patient's behavior
during the interview
Both the content and process of the interview should be
documented. Providing only the patient's verbal responses
creates a skewed picture of the patient. Writing that the patient is
uncooperative is subjectively worded. An objective description
of patient behavior is preferable. Analysis of the reasons for the
patient's behavior is speculation, which is inappropriate.
Foundation for Safe and Effective Care) Questions With
Complete Solutions
A new staff nurse completes 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. Establish therapeutic relationships.
c. Prescribe psychotropic medications.
d. Individualize nursing care plans. Correct Answers c.
Prescribe psychotropic medications.
Prescriptive privileges are granted to Master's-prepared nurse
practitioners who have taken special courses on prescribing
medications. The nurse prepared at the basic level performs
mental health assessments, establishes relationships, and
provides individualized care planning.
A newly admitted patient with major depression has lost 20
pounds over the past month 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: Less than body requirements
,b. Chronic low self-esteem
c. Risk for suicide
d. Hopelessness Correct Answers c. Risk for suicide
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 a suicide attempt.
A nurse asks a patient, "If you had fever and vomiting for 3
days, what would you do?" Which aspect of the mental status
examination is the nurse assessing?
a. Behavior
b. Cognition
c. Affect and mood
d. Perceptual disturbances Correct Answers b. Cognition
Assessing cognition involves determining a patient's judgment
and decision-making capabilities. In this case, the nurse expects
a response of, "Call my doctor" if the patient's cognition and
judgment are intact. If the patient responds, "I would stop
eating" or "I would just wait and see what happened," the nurse
would conclude that judgment is impaired. The other options
refer to other aspects of the examination.
, A nurse assesses a patient who reluctantly participates in
activities, answers questions with minimal responses, and rarely
makes eye contact. What information should be included when
documenting the assessment? Select all that apply.
a. Uncooperative patient
b. Patient's subjective responses
c. Only data obtained from the patient's
verbal responses
d. Description of the patient's behavior
during the interview
e. Analysis of why the patient is
unresponsive during the interview Correct Answers b. Patient's
subjective responses
d. Description of the patient's behavior
during the interview
Both the content and process of the interview should be
documented. Providing only the patient's verbal responses
creates a skewed picture of the patient. Writing that the patient is
uncooperative is subjectively worded. An objective description
of patient behavior is preferable. Analysis of the reasons for the
patient's behavior is speculation, which is inappropriate.
