Chapter 11: Implementing the Nursing Process: Standards of Practice and Professional Performance My Nursing Test Banks

Chapter 11: Implementing the Nursing Process: Standards of Practice and Professional Performance

Test Bank

MULTIPLE CHOICE

1. A nurse teaching a patient about the effects and side effects of the prescribed medication bases the plan on the knowledge that learning is more effective when:

a.

patients are actively included in the process.

b.

topics are introduced only when the patient expresses an interest.

c.

nurses establish realistic goals for learning on behalf of the patient.

d.

patients have responsibility for directing the teaching-learning process.

ANS: A

Learning is more effective when patients participate in the learning experience. By including patients as active participants, the nurse helps restore their sense of control over their life and over their responsibility for their own actions.

DIF: Cognitive Level: Comprehension REF: Text Page: 152

TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance

2. A nurse interviewed a reluctant patient who answered questions with minimal responses and rarely made eye contact. When documenting baseline data collected in the interview, the nurse should include:

a.

interview content only.

b.

a description of the process of the interview.

c.

both the content and the process of the interview.

d.

both factual data about the patient and the nurses emotional reaction.

ANS: C

It is important to document both baseline content and process. In addition to the verbal content of the interview, the patients nonverbal messages and the nurses reactions to the patient give important clues to the patients state.

DIF: Cognitive Level: Application REF: Text Page: 150

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

3. While gathering a baseline history about a patient, a nurse is told by a team social worker that the patient acts weird and has bad hygiene. The nurses responsibility is to:

a.

accept the data without question.

b.

form impressions based on data personally gathered.

c.

document the impression of the team social worker.

d.

discuss the social workers impression with the patient.

ANS: B

In using information from secondary sources, nurses should not simply accept the assessment of another health care team member; instead, they should apply the information they obtain to their nursing framework for data collection and formulate their own impressions and diagnoses. This brings another perspective to the work of the health care team and promotes an unbiased receptivity to patients and their problems.

DIF: Cognitive Level: Application REF: Text Page: 152

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

4. To obtain the clearest clinical information about a patient, a nurse who used several secondary sources, including the patients spouse and the report of the admitting psychiatrist, will seek validation from:

a.

the patient.

b.

psychiatric nursing textbooks.

c.

the patients extended family.

d.

the use of psychiatric behavioral rating scales.

ANS: A

Patients should be regarded as a source of validation.

DIF: Cognitive Level: Application REF: Text Page: 150

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

5. If physicians wish to understand the nursing equivalent of the medical DSM-IV-TR, they should seek an understanding of the:

a.

nursing diagnoses.

b.

nursing process.

c.

behavioral rating scales.

d.

computerized medical records.

ANS: A

A medical diagnosis is the health problem or disease state of the patient. Nursing diagnoses identify patterns of response to actual or potential psychiatric illnesses and mental health problems. Nursing diagnoses proceed from inductive and deductive reasoning, logical decision making, knowledge of normal parameters, and sociocultural sensitivity.

DIF: Cognitive Level: Application REF: Text Page: 152

TOP: Nursing Process: Analysis

MSC: NCLEX: Safe, Effective Care Environment: Management of Care

6. Which goal should be given the highest priority?

a.

Reduction of anxiety

b.

Alleviation of depression

c.

Enhancement of self-esteem

d.

Protection from self-destructive impulses

ANS: D

Patient safety is always of paramount concern. After safety for the patient has been established, other goals of treatment can be effectively addressed.

DIF: Cognitive Level: Application REF: Text Page: 156

TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity

7. A nurse who is new to the mental health setting is having difficulty writing meaningful outcome criteria. The nurses mentor should suggest which source to best assist the nurse?

a.

Nursing Outcomes Classification (NOC)

b.

Nursing Interventions Classification (NIC)

c.

North American Nursing Diagnosis Association International (NANDA-I)

d.

Diagnostic and Statistical Manual of Mental Disorders, ed 4, text revision

(DSM-IV-TR)

ANS: A

NOC stands for Nursing Outcomes Classification. The outcomes listed can serve as models for nurses.

DIF: Cognitive Level: Application REF: Text Page: 153

TOP: Nursing Process: Outcome Identification

MSC: NCLEX: Safe, Effective Care Environment: Management of Care

8. Which is a well-written short-term goal for a socially withdrawn patient who tells a nurse of a wish to reduce social isolation? By day 2, the patient will:

a.

express desire to go shopping.

b.

participate in one unit activity.

c.

become more independent.

d.

be more outgoing.

ANS: B

Short-term goal statements should be specific, measurable, attainable, current, adequate, and mutually accepted. The correct option includes a timeframe as well as meeting the existing criteria for a short-term goal. More outgoing and more independent are not measurable. Expressing a desire to go shopping is a statement rather than an action.

DIF: Cognitive Level: Application REF: Text Pages: 153-154

TOP: Nursing Process: Outcome Identification

MSC: NCLEX: Psychosocial Integrity

9. A patient is admitted with a diagnosis of bipolar disorder, manic phase, and displays extreme hyperactivity, agitation, talkativeness, and emotional lability. Which is the highest priority nursing diagnosis?

a.

Risk for injury related to extreme hyperactivity

b.

Disturbed thought processes related to manic state

c.

Impaired social interaction related to excessive verbalization

d.

Impaired sensory perception related to biochemical alterations

ANS: A

This nursing diagnosis deals with patient safety, a primary concern for the psychiatric nurse caring for a patient exhibiting symptoms of mania.

DIF: Cognitive Level: Application REF: Text Page: 152

TOP: Nursing Process: Analysis MSC: NCLEX: Psychosocial Integrity

10. A nurse is working with a patient with depression. To best help the patient translate insight into action, a major nursing challenge will be to:

a.

promote self-care activities.

b.

consult appropriate resources.

c.

build adequate incentives to change.

d.

identify ineffective behavior patterns.

ANS: C

Building adequate incentives to change is critical to translating insight into action. The nurse should help the patient see the consequences of each action and help the patient understand that old patterns do more harm than good. The patient will not learn new patterns until the motivation to acquire them is greater than the motivation to retain the old ones.

DIF: Cognitive Level: Analysis REF: Text Page: 155

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

11. Nursing interventions that have the greatest validity are those that:

a.

are used by nurse clinicians.

b.

are prescribed by physicians.

c.

have been investigated by nurse researchers.

d.

are based on evidence of the efficacy of the intended treatment.

ANS: D

Nursing interventions that have proven successful by research methods (evidence-based psychiatric nursing) should be the ones chosen for use by clinicians.

DIF: Cognitive Level: Comprehension REF: Text Page: 155

TOP: Nursing Process: Implementation

MSC: NCLEX: Safe, Effective Care Environment: Management of Care

12. Nursing behaviors associated with the implementation phase of the nursing process are concerned with:

a.

regular, in-depth self-analysis.

b.

participating in quality improvement activities.

c.

carrying out interventions and generating alternatives.

d.

comparing patient responses and expected outcomes.

ANS: C

Nursing behaviors relating to the implementation phase of the nursing process include considering available resources, implementing nursing activities, generating alternatives, and coordinating care with other team members.

DIF: Cognitive Level: Comprehension REF: Text Page: 151

TOP: Nursing Process: Implementation

MSC: NCLEX: Safe, Effective Care Environment: Management of Care

13. A nurse clinician is attempting to explain the evaluation phase of the nursing process to a student. Which statement would help the student grasp the essentials?

a.

It is a continuous, active process.

b.

Patient and family participation is optional.

c.

It takes place at the time of termination of services.

d.

It is optional since it is based on the patients readiness.

ANS: A

Evaluation is a continuous, active process that begins early in the relationship and continues throughout. It is an activity that requires patient and family participation, because it is based on previously identified goals and level of satisfaction. It should be documented to demonstrate the value of nursing services to consumers.

DIF: Cognitive Level: Comprehension REF: Text Pages: 155-156

TOP: Nursing Process: Evaluation

MSC: NCLEX: Safe, Effective Care Environment: Management of Care

14. A psychiatric nurse clinician is heard calling nurse educators the experts and frequently refers to nurse administrators and researchers as those who know it all. This nurse can be assessed as having a problem with:

a.

ethics.

b.

education.

c.

collegiality.

d.

resource use.

ANS: C

Collegiality means regarding other nurses as partners in caregiving who are valued and respected for their unique contributions regardless of educational, experiential, or specialty background. It suggests that nurses view themselves as members of a profession and that nurses trust, remain loyal to, and demonstrate commitment to other nurses.

DIF: Cognitive Level: Application REF: Text Pages: 158-159

TOP: Nursing Process: Assessment

MSC: NCLEX: Safe, Effective Care Environment: Management of Care

15. Which action best demonstrates a nurse displaying accountability?

a.

Volunteering to serve on a hospital committee

b.

Notifying the nurse manager when a medication error occurs

c.

Planning patient care strategies for a newly admitted adult patient

d.

Coordinating a patient-centered conference for the health care team

ANS: B

Accountability is best demonstrated by taking responsibility for ones own actions.

DIF: Cognitive Level: Application REF: Text Pages: 155-156

TOP: Nursing Process: Implementation

MSC: NCLEX: Safe, Effective Care Environment: Management of Care

16. A new psychiatric staff nurse is asked to be a member of the Quality Improvement (QI) Committee. The nurse should be motivated to agree to do this because:

a.

QI participation is a requirement stated in the nurses job description.

b.

evaluation of quality of care is a standard of professional performance.

c.

salary increments depend on performance variables like committee work.

d.

QI is an activity mandated by the accrediting agency, The Joint Commission.

ANS: B

Professional performance standards state the following: The psychiatric-mental health nurse systematically evaluates the quality of care and effectiveness of psychiatric-mental health practice.

DIF: Cognitive Level: Application REF: Text Page: 156

TOP: Nursing Process: Evaluation

MSC: NCLEX: Safe, Effective Care Environment: Management of Care

17. A staff nurse is told at orientation that the department has a clinical advancement program in place. On what criterion is advancement usually based?

a.

Desire for professional growth

b.

Acceptance of peer feedback

c.

Advanced application of nursing skills

d.

Attainment of an advanced degree in nursing

ANS: C

Clinical advancement programs allow the nurse to be promoted and economically rewarded for providing direct patient care. Such programs identify levels of professional development in nursing based on increased critical thinking and advanced application of nursing skills.

DIF: Cognitive Level: Comprehension REF: Text Page: 154

TOP: Nursing Process: N/A

MSC: NCLEX: Safe, Effective Care Environment: Management of Care

18. What is the major difference between supervision and therapy?

a.

Therapy is more intensive; supervision is less structured in its focus.

b.

Supervision extends to all aspects of life, whereas therapy is limited to problem areas.

c.

Supervision teaches psychotherapeutic skills, whereas therapy changes personal coping patterns.

d.

Therapy uses transference, whereas supervision focuses on only personal limitations.

ANS: C

Despite its intensity, supervision is not therapy; its purposes are different. Supervision aims to teach psychotherapeutic skills, whereas therapy seeks to alter a persons characteristic patterns of coping.

DIF: Cognitive Level: Comprehension REF: Text Page: 158

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

19. A nurse registers for a DSM-IV-TR update workshop. This is an example of adherence to the standard of professional performance that refers to:

a.

education.

b.

ethical standards.

c.

resource utilization.

d.

performance appraisal.

ANS: A

The standard about education reads as follows: The psychiatric-mental health nurse acquires and maintains current knowledge in nursing practice. Nursing conditions include intellectual curiosity, desire for professional growth, and access to new information.

DIF: Cognitive Level: Application REF: Text Page: 157

TOP: Nursing Process: N/A MSC: NCLEX: Psychosocial Integrity

20. According to the nursing standard related to research, a novice psychiatric-mental health nurse with an associates degree can be expected to:

a.

engage with other staff in the research process.

b.

use research findings to improve clinical practice.

c.

plan small, independent, data-gathering research projects.

d.

collaborate in proposal development and data collection and analysis.

ANS: B

At the beginning level a staff nurse who has no advanced degrees can be expected to use research findings in practice, with supervision.

DIF: Cognitive Level: Application REF: Text Page: 160

TOP: Nursing Process: Implementation

MSC: NCLEX: Safe, Effective Care Environment: Management of Care

MULTIPLE RESPONSE

1. As a nurse formulates expected outcomes for a patient who will be taking an antidepressant medication, consideration should be given to which psychosocial domain? (Select all that apply.)

a.

Psychomotor

b.

Cognitive

c.

Affective

d.

Conscious

e.

Process

ANS: A, B, C

The three domains that should be considered are cognitive, affective, and psychomotor. Cognitive relates to intellectual, affective is concerned with values, and psychomotor is concerned with the mastery of motor skills. Compliance with a medication regimen requires one to know the dose and dosing intervals, value the effects of the medication, and have the ability to obtain the medication.

DIF: Cognitive Level: Application REF: Text Page: 153

TOP: Nursing Process: Outcome Identification

MSC: NCLEX: Psychosocial Integrity

2. The goal of the nursing care plan is to answer which question regarding the achievement of patient wellness? (Select all that apply.)

a.

Why

b.

When

c.

How

d.

Where

e.

Who

ANS: A, C

The nursing care plan includes interventions designed to achieve designated outcomes and which answer the question, How/by what means can this be accomplished? The rationale that is developed for the selection of specific interventions answers the Why?

DIF: Cognitive Level: Application REF: Text Page: 154

TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity

3. A new staff nurse has set a personal goal of gaining greater autonomy over practice. The component of autonomy that the nurse will need to focus on is: (Select all that apply.)

a.

valuing reciprocal interactions.

b.

participating in decision making.

c.

exercising control over nursing tasks.

d.

assuming responsibility for personal actions.

e.

identifying the ethical components of practice.

ANS: B, C

Autonomy has two interrelated components: (1) control over nursing tasks, which means having the opportunity for independent thought and action, having use of time, skills, and ability, having authority and responsibility for implementing goals related to quality of care, and being able to initiate changes, and (2) participation in decision making regarding quality standards, ones job context, and institutional policies.

DIF: Cognitive Level: Comprehension REF: Text Page: 155

TOP: Nursing Process: N/A

MSC: NCLEX: Safe, Effective Care Environment: Management of Care

4. A staff nurse is told in orientation to expect to receive performance appraisals in various forms. The nurse can expect that these will be: (Select all that apply.)

a.

collaborative practice.

b.

interdisciplinary.

c.

administrative.

d.

professional.

e.

clinical.

ANS: C, E

Administrative performance appraisal involves the review, management, and regulation of competent psychiatric nursing practice in which actual performance is compared with role expectations in a formal way. Clinical performance appraisal is guidance provided through a mentoring relationship with a more experienced, skilled, and educated nurse.

DIF: Cognitive Level: Application REF: Text Page: 158

TOP: Nursing Process: Evaluation

MSC: NCLEX: Safe, Effective Care Environment: Management of Care

5. When the cost of a patients prescribed medication is discussed, the interdisciplinary team is engaging in patient-focused: (Select all that apply.)

a.

discharge.

b.

participation.

c.

collaboration.

d.

advocacy.

e.

resource utilization.

ANS: C, D, E

The standard for resource use states that the psychiatric-mental health nurse/care team should collaborate when considering safety, effectiveness, and cost when planning and delivering patient care. Treatment decisions must be made in such a way as to maximize resources and maintain quality of care while engaging in patient advocacy.

DIF: Cognitive Level: Application REF: Text Pages: 159-161

TOP: Nursing Process: Planning

MSC: NCLEX: Safe, Effective Care Environment: Management of Care

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