Chapter 9: Assessment Strategies and the Nursing Process

Chapter 9: Assessment Strategies and the Nursing Process

Complete Chapter Questions With Answers

Sample Questions Are Posted Below

MULTIPLE CHOICE

1)   A new graduate with an associate’s degree in nursing has just completed the new staff orientation to the psychiatric unit. The aspect of nursing care this nurse must have an advanced practice nurse perform is

ANS:   D

Prescriptive privileges are granted to masters-prepared nurse practitioners who have taken special courses on prescribing medication. The nurse prepared at the basic level is permitted to perform mental health assessments, establish relationships, and provide individualized care planning.

DIF:    Cognitive Level: Application             REF:    Text Page: 149

TOP:    Nursing Process: Implementation

MSC:   NCLEX: Safe, Effective Care Environment;

2)   Admission data for a newly admitted client who is severely depressed reveal he has lost 20 pounds over the past month, has chronic low self-esteem, and has both the intent and a plan for committing suicide. He has been taking a selective serotonin reuptake inhibitor for 1 week without remission of symptoms. The priority nursing diagnosis is

ANS:   C

Risk for suicide is the priority diagnosis when the client has both suicidal ideation and has developed a plan to carry out the suicidal intent. Imbalanced nutrition and chronic low self-esteem are viable nursing diagnoses, but these problems do not affect client safety as urgently as would a suicide attempt. Ineffective protection would be of greater concern if the client were taking risperidone or an immune suppressant drug.

DIF:    Cognitive Level: Analysis                  REF:    Text Page: 145

TOP:    Nursing Process: Nursing Diagnosis

MSC:   NCLEX: Safe, Effective Care Environment;

3)   Admission data for a newly admitted client who is severely depressed reveal he has lost 20 pounds over the past month, has chronic low self-esteem, and has both the intent and a plan for committing suicide. He has been taking a selective serotonin reuptake inhibitor for 1 week without remission of symptoms. The nurse must plan interventions directed toward meeting the client outcome: Client will refrain from gestures and attempts at killing self. The nursing intervention most directly related to this outcome is

ANS:   D

Option D is the only option related to client safety. Option A relates to nutrition. Option B relates to self-esteem. Option C relates to medication therapy.

DIF:    Cognitive Level: Analysis

REF:    Text Page: 146, Text Page: 147, Text Page: 148

TOP:    Nursing Process: Planning

MSC:   NCLEX: Safe, Effective Care Environment;

4)   The client’s nursing diagnosis is disturbed sleep pattern related to anxiety. The desired outcome is that client will sleep for a minimum of 5 hours nightly by October 31. On November 1 review of sleep data for the 6 days of hospitalization shows the client sleeps an average of 4 hours nightly and takes a 2-hour afternoon nap. The outcome can be evaluated as

ANS:   D

Although the client is sleeping 6 hours daily, the total is not in one uninterrupted session at night. Therefore the outcome must be evaluated as never demonstrated.

DIF:    Cognitive Level: Analysis                  REF:    Text Page: 149

TOP:    Nursing Process: Evaluation

MSC:   NCLEX: Safe, Effective Care Environment;