Upgrade to remove ads
Only $35.99/year

Chapter 7 Nursing Process and QSEN

Terms in this set (30)

As of the late 1990s, the Institute of Medicine found the United States lacking in which areas of health care? Select all that apply.

Access to a broad range of specialists

A sufficient number of licensed nurses

Quality care across geographic locations

Services rooted in evidence-based practices

Respectful, responsible, and patient-centered care
Quality care across geographic locations
Services rooted in evidence-based practices
Respectful, responsible, and patient-centered care

Reports from the Institute of Medicine (IOM) found the American health care system lacking in a number of areas, including quality care across geographic locations, services based on evidence-based practice, and respectful and responsible care that is patient centered. These reports did not find access to specialists or number of licensed nurses to be lacking.

p. 76
An older adult client's spouse died 2 months ago. Since then, he has stopped bathing and changing his clothes regularly. He has expressed to the nurse that he is lonely and doesn't wish to live without his spouse. What nursing intervention is most appropriate for this client?

Use physical restraints to help the client refrain from self-harm.

Search the client and personal belongings for weapons daily.

Place the client in seclusion to be sure his environment contains nothing he can use to self-harm.

Help the client identify a support network of friends, family, and care providers.
Help the client identify a support network of friends, family, and care providers.

The most appropriate intervention is to help the client identify a support network of friends, family, and care providers. Using physical restraints is only appropriate when the client is in immediate danger and all other less restrictive interventions have been tried first. Searching the client for weapons daily is unlikely to be necessary for the client at present. Placing the client in seclusion may make him feel more isolated, and the client should always be maintained in the least restrictive environment.

Test-Taking Tip: Multiple choice questions can be challenging, because students think they will recognize the right answer when they see it or that the right answer will somehow stand out from the other choices. This is a dangerous misconception. The more carefully the question is constructed, the more each of the choices will seem like the correct response.

p. 85
According to NANDA-I, which aspect of a standard nursing diagnosis is excluded in "risk for" diagnoses?

Problem

Etiology

Supporting data

Defining characteristics
Defining characteristics

NANDA-I suggests that when making a "risk for" diagnosis, the diagnosis should include the risk diagnoses and risk factors (risk-related behaviors) that predispose the individual to a potential problem. Because the problem hasn't yet arisen, NANDA-I states that there can be no "related etiological factors."

Test-Taking Tip: Do not worry if you select the same numbered answer repeatedly, because there usually is no pattern to the answers.

p. 83
A nurse assesses a new client whose chief concern is "daily crying spells." Which comment from the client would prompt the nurse to suspect a medical reason is causing the problem rather than depression?

"I usually drink two or three cups of coffee in the morning."

"I often have headaches, especially when the pollen count is high."

"Years ago I had thyroid problems, but they cleared up and I stopped the medicine."

"I recently had three moles removed because my doctor thought they were suspicious."
"Years ago I had thyroid problems, but they cleared up and I stopped the medicine."

Endocrine disorders like hypothyroidism may have the clinical appearance of depression, and the client has indicated that he or she no longer takes medication for the thyroid problems. Crying spells or symptoms of depression would not be linked to drinking coffee, allergies to pollen, or the appearance of moles.

pp. 79-80
What is the primary goal of Quality and Safety Education for Nurses (QSEN)?

To assess all clients for suicide risk and prioritize the safety of clients at risk for suicide

To inform clients in a culturally competent manner about the need for structure, safety, and quality of care

To ensure that an individual's health information is properly protected while receiving high-quality health care

To prepare nurses with the knowledge, skills, and attitudes required to enhance quality, care, and safety in the health care setting
To prepare nurses with the knowledge, skills, and attitudes required to enhance quality, care, and safety in the health care setting

The primary goal of QSEN is to prepare nurses with the knowledge, skills, and attitudes required to enhance quality, care, and safety in the health care setting. It is important for nurses to assess all clients for suicide risk and prioritize the safety of clients at risk for suicide. Milieu therapy involves informing clients in a culturally competent manner about the need for structure, safety, and quality of care. The primary goal of the Health Insurance Portability and Accountability Act (HIPAA) is to ensure that an individual's health information is properly protected while receiving high-quality health care.

p. 76
What are the advantages of narrative charting?

Is well structured

Provides consistent organization of data

Can address any event or behavior

Explains flow sheet findings

Uses a common form of expression
Can address any event or behavior
Explains flow sheet findings
Uses a common form of expression

Narrative charting can address any event or behavior and explain flow sheet findings. It also uses a common form of expression (narrative writing) that reduces the need to learn a system. Narrative charting is not structured and does not provide consistent organization of data. These are features of problem-oriented charting ("soapie").

Test-Taking Tip: Read the question carefully before looking at the answers: (1) Determine what the question is really asking, and look for key words; (2) read each answer thoroughly, and see if it completely covers the material the question asks; and (3) narrow the choices by immediately eliminating answers you know are incorrect.

p. 88
What is the goal of a nurse's self-awareness assessment?

To understand how bias can distort the nurse's understanding of the client

To eliminate personal biases and avoid bringing emotion to the clinical setting

To become familiar with the customs and practices of other cultures and religions

To identify personal "off days" and ask a colleague to cover the nurse's shifts when they occur
To understand how bias can distort the nurse's understanding of the client

We all have personal biases, and the nurse should understand how his or her own biases can distort his or her understanding of clients. It is impossible to eliminate personal biases, and some degree of emotion is appropriate in the clinical setting to provide compassionate care. Becoming familiar with different cultures and religions is welcome, but the nurse's personal biases will persist in the presence of this knowledge. Nurses should learn how to work through their "off days" without interfering with providing quality care.

p. 82
What characteristics define client outcomes? Select all that apply.

Variable

Identified prior to the nursing diagnosis

Measurable

Reflective of client's actual state

Selected from a NANDA-I list
Variable
Measurable
Reflective of client's actual state

Outcomes are variable, measurable, and stated in terms that reflect a client's actual state. They are informed by the nursing diagnosis, which must be determined first. NANDA-I lists nursing diagnoses, not client outcomes.

p. 88
Which factors should be considered to ensure a plan of care is patient-centered? Select all that apply.

The most recent and relevant scientific research

The available community resources and technology

The client's capabilities given age, physical strength, and condition

The client's willingness to change

The client's preferences, health practices, and goals
The available community resources and technology
The client's capabilities given age, physical strength, and condition
The client's willingness to change
The client's preferences, health practices, and goals

When planning care, the nurse should consider the client's capabilities given his or her age, physical strength, condition, and willingness to change; the client's preferences, health practices, coping styles, developmental level, and recovery goals (to name but a few); and the actual available community resources and technology. The most recent and relevant scientific research should be considered to ensure that care is evidence based but is not specific to the patient-centered approach.

p. 85
Which statement made by the nurse concerning a client experiencing musculoskeletal pain demonstrates attention to the evaluation portion of the nursing process?

"The client's daughter confirmed that he had knee replacement surgery 3 years ago."

"The client's inability to ambulate affectively without assistance is a priority problem."

"After 2 weeks of physical therapy, the client can safely walk the length of the hallway."

"The client has expressed a strong fear of falling when asked to walk without assistance."
"After 2 weeks of physical therapy, the client can safely walk the length of the hallway."

The nursing process includes assessment, nursing diagnosis, outcome identification, planning, implementation, and evaluation. Stating that the client is now able to safely ambulate the length of the hallway demonstrates an expected outcome. The nurse stating the client's daughter confirmed that the client had a knee replacement surgery 3 years ago is incorrect, because it demonstrates nursing assessment. The nurse stating that the client is unable to ambulate effectively is incorrect, because it demonstrates nursing diagnosis. The nurse stating that the client expressed a fear of falling when asked to walk without assistance is incorrect, because it demonstrates nursing diagnosis.

p. 76
On an inpatient unit, one client assaults another client, resulting in a small laceration. Considering both clients' rights to confidentiality, how will the nurse effectively document this event?

Ensure unit safety by documenting the hostile and combative characteristics of the assaulting client.

Document in each client's medical record the events and actions taken, using the initials of the other client involved.

Document in both clients' medical records that an occurrence (incident) report was prepared according to agency policy.

Verbally report the events to other team members and minimize written documentation in order to reduce potential legal consequences.
Document in each client's medical record the events and actions taken, using the initials of the other client involved.

Documenting in each record using the initials of the other client involved is the only approach that protects both clients' rights to confidentiality. Documenting the assaulting client's hostile characteristics does not address confidentiality, and the nurse should avoid defaming clients. The nurse should never document in a medical record that an occurrence report was prepared, because this is generally a privileged communication between the hospital and the hospital's attorney. Documentation is critical to protecting the nurse and other staff members, so the nurse should never minimize documentation.

89,pp. 84
A 55-year-old lives 100 miles from her parents and mother-in-law. In the past year, her father had back surgery, her mother broke her hip, and her mother-in-law had a cardiac event. Which nursing diagnosis is most applicable to the 55-year-old?

Risk for complicated grieving related to impending deaths of parents

Risk for injury related to frequent long drives to care for aging parents

Risk for chronic low self-esteem related to overwhelming responsibilities

Risk for caregiver role strain related to responsibilities for care of aging parents
Risk for caregiver role strain related to responsibilities for care of aging parents

Risk diagnoses are based on the high probability that an event will occur in a vulnerable person. The diagnosis must be supported by the risk factors that predispose the individual to the event. In this case, the distance and the recent health problems the individual's family members have experienced predispose her to caregiver role strain as her responsibilities increase. None of the family members have a terminal illness, so it is not known if their deaths are impending. Injury related to long drives is unlikely and therefore not a risk factor. There is no evidence that the woman's self-esteem is being affected by her responsibilities, so this is not a risk factor.
What characteristics define client outcomes?

Variable

Identified prior to the nursing diagnosis

Measurable

Reflective of client's actual state

Selected from a NANDA-I list
Variable
Measurable
Reflective of client's actual state

Outcomes are variable, measurable, and stated in terms that reflect a client's actual state. They are informed by the nursing diagnosis, which must be determined first. NANDA-I lists nursing diagnoses, not client outcomes.
p. 88
What are the disadvantages of problem-oriented charting?

Limits entries to problems

Commonly results in inclusion of unnecessary information

Requires time and effort to structure the information

Frequently leads to omission of elements of the nursing process

May result in loss of data about progress
Problem-oriented charting limits entries to problems, requires time and effort to structure the information, and may result in loss of data about progress. Disadvantages of narrative charting include that it commonly results in inclusion of unnecessary information and frequently leads to omission of elements of the nursing process.
p. 88
What is the goal of a nurse's self-awareness assessment?

To understand how bias can distort the nurse's understanding of the client

To eliminate personal biases and avoid bringing emotion to the clinical setting

To become familiar with the customs and practices of other cultures and religions

To identify personal "off days" and ask a colleague to cover the nurse's shifts when they occur
To understand how bias can distort the nurse's understanding of the client

We all have personal biases, and the nurse should understand how his or her own biases can distort his or her understanding of clients. It is impossible to eliminate personal biases, and some degree of emotion is appropriate in the clinical setting to provide compassionate care. Becoming familiar with different cultures and religions is welcome, but the nurse's personal biases will persist in the presence of this knowledge. Nurses should learn how to work through their "off days" without interfering with providing quality care.
p. 82
What phrase should the nurse include in all nursing diagnoses related to health promotion?

Risk for

Willingness to

Coping skills

Readiness for enhanced
Readiness for enhanced

Health promotion diagnoses are always stated in the form of "readiness for enhanced" and supported by the data/defining characteristics. "Risk for" is not relevant to a health promotion diagnosis. "Willingness to" and "coping skills" may be included in some, but not all, health promotion diagnoses when relevant.
p. 83
A client from which demographic group is most likely to have concerns about confidentiality and need reassurance from the nurse during a clinical interview?

Young children

Adolescents

Older adults

Adults who do not speak English
Adolescents

All clients are concerned with confidentiality. This is especially true for adolescents, who may fear that anything they say to the nurse will be repeated to their parents. At least part of the interview should be conducted without the parent/caregiver being present. Young children are unlikely to have much awareness of confidentiality, although they may be reluctant to share information related to abuse. Older adults and clients who do not speak English may also have confidentiality concerns, but adolescents are most likely to have privacy concerns and to require reassurance.
p. 78
Informing clients about their rights and responsibilities is an aspect of which nursing intervention?

Milieu therapy

Integrative therapy

Coordination of care

Health teaching and promotion
Milieu therapy

Milieu therapy includes informing clients about their rights and responsibilities, as well as the need for structure, maintenance of a safe environment, and limits set on the unit. Integrative therapy includes interventions that complement pharmacological and biological therapies. Health teaching and promotion includes teaching coping skills, self-care activities, stress management, problem-solving skills, relapse prevention, and conflict management.
p. 86
Which question will the nurse ask the client during a psychosocial assessment to determine existing social patterns?

"Please describe your typical day."

"How do you spend your free time?"

"Do you have a religious affiliation?"

"With whom do you talk to when you are upset?"
"Please describe your typical day."

To gather information about the client's social patterns, the nurse would ask him or her to describe a typical day. Asking the client how his or her free time is spent is incorrect, because it is associated with interests and abilities. Asking the client if he or she has a religious affiliation is incorrect, because it is associated with the spiritual aspect of the psychosocial assessment. Asking the client with whom he or she talks to when the client is upset is incorrect, because it is a part of the coping abilities portion of the psychosocial assessment.

Test-Taking Tip: Look for answers that focus on the patient or are directed toward feelings.
p. 81
What is the primary goal of the Health Insurance Portability and Accountability Act (HIPAA)?

To prepare nurses with the knowledge, skills, and attitudes required to enhance quality, care, and safety in the health care setting

To ensure that an individual's health information is properly protected while receiving high-quality health care

To assess all clients for suicide risk and prioritize the safety of clients at risk for suicide

To inform clients in a culturally competent manner about the need for structure, safety, and quality of care
To ensure that an individual's health information is properly protected while receiving high-quality health care

The primary goal of HIPAA is to ensure that an individual's health information is properly protected while receiving high-quality health care. The primary goal of Quality and Safety Education for Nurses (QSEN) is to prepare nurses with the knowledge, skills, and attitudes required to enhance quality, care, and safety in the health care setting. It is important for nurses to assess all clients for suicide risk and prioritize the safety of clients at risk for suicide. Milieu therapy involves informing clients in a culturally competent manner about the need for structure, safety, and quality of care.
p. 77
Which rating scale is used in the evaluation and monitoring of schizophrenia?

Beck Inventory

Global Deterioration Scale (GDS)

Brief Psychiatric Rating Scale (BPRS)

Patient Health Questionnaire (PHQ-9)
Brief Psychiatric Rating Scale (BPRS)

The Brief Psychiatric Rating Scale (BPRS) is used in the evaluation and monitoring of schizophrenia. The Beck Inventory and Patient Health Questionnaire (PHQ-9) are used in depression. The Global Deterioration Scale (GDS) is used to evaluate and monitor cognitive function.
p. 82
What is one purpose of the psychosocial assessment?

To identify stressors and coping mechanisms

To evaluate current cognitive processes

To differentiate physical- and somatic-based symptoms

To monitor severity of depression
To identify stressors and coping mechanisms

Identification of stressors and coping mechanisms occurs during the psychosocial assessment. Evaluating current cognitive processes is the main purpose of the mental status evaluation (MSE). Thorough physical and psychological health evaluations will differentiate physical- and somatic-based symptoms. A number of standardized rating scales are used to evaluate and monitor the severity of depression.
p. 80
The nurse is interviewing a client who immigrated from India. The nurse asks questions about the client's home culture and religious practices in addition to questions about medical history. What does this combination of questions most represent?

Holistic approach to care

Performance-based learning

Milieu management

Evidence-based practice
Holistic approach to care

The holistic approach to care views the client as a complex blend of many parts. It involves awareness of psychological, social, cultural, environmental, functional, and spiritual issues as well as ethnicity, sexual orientation, and age. The use of clinical simulations is an example of performance-based learning. Milieu management includes orienting clients to their rights and responsibilities and informing them in a culturally competent manner about the need for structure, maintenance of a safe environment, and limits set on the unit. Evidence-based practice integrates the best current evidence with clinical practice to deliver optimal health care.

p. 77
A 60-year-old client reports, "I stopped taking my medication shortly after it became unsafe for me to drive due to my health problems." What is the most appropriate action by the nurse?

Have the client sign a release form to protect against malpractice lawsuits.

Question the client about difficulty obtaining the medication.

Contact the appropriate license-issuing department to request the client's license be reissued.

Make a note in the client's chart that the client was "nonadherent" with medication instructions.
Question the client about difficulty obtaining the medication.

When a client does not follow medication or treatment plans, the nurse should find out what is going on in the client's life to challenge his or her adherence. The nurse should help the client brainstorm solutions to the challenges that come up. The best way to protect against malpractice is to meticulously document rationale for treatment, offer clear explanations what the client should do, and note whether the client actually complied with that advice. The nurse should not request that the client's license be reissued if the client presents a danger behind the wheel. Although using the term "nonadherent" is preferred over "noncompliant," simply making a note of this in the chart is less appropriate that having an extended conversation about the issue with the client. The nurse should not have a client sign a release form in this instance.

p. 87
The nurse is assessing a 9-year-old child. The child's parent reports that the child wakes up several times throughout the night crying. The nurse finds that the child has had multiple fractures over the past year. What is the nurse's most appropriate action?

Stop the interview, and use observation of the child at play as the main source of information.

Avoid using any secondary sources for data collection, because doing so would violate the child's confidentiality.

Interview the child separately from the parents, so the child is less reluctant to give details about possible physical abuse.

Ask the child to leave the room for the remainder of the interview, because the parents are the best source for determining the child's inner feelings.
Interview the child separately from the parents, so the child is less reluctant to give details about possible physical abuse.

Multiple fractures over the past year, along with chronic nightmares, may be suggestive of child abuse. The nurse should interview the child separately from the parents, so the child is less reluctant to give details about possible physical abuse. Assessment of children should be accomplished by a combination of interview and observation. Secondary sources include family, friends, neighbors, and others with knowledge about the child. They can be invaluable sources of data about the child, and such data can be gathered without violating the child's confidentiality. Although the parents are an important source of information, the child is the best source for determining his or her own inner feelings and emotions.

pp. 77-78
Which statements are true about mental illness in children?

Regression is a hallmark of psychiatric disorders in children.

Interviewing a child without a caregiver present is prohibited.

An estimated one in 20 children in the United States suffer from a mental illness.

Observing a child at play is an effective means of assessing psychiatric well-being.

Parents and guardians are the best source for determining a child's inner feelings.
-Regression is a hallmark of psychiatric disorders in children.
-Observing a child at play is an effective means of assessing psychiatric well-being.

Regressing to a previous stage of development is a hallmark of psychiatric disorders in children. For example, thumb sucking is normal for toddlers but not older children. Observing a child at play is an effective means of assessing psychiatric well-being and should be combined with the clinical interview. Interviewing a child without a caregiver present may be appropriate if a child is reluctant to share information, especially in cases of suspected abuse. An estimated 1 in 10 children in the United States suffers from a mental illness. Parents and guardians may provide important information, but the child is the best source in determining his or her own inner feelings.

pp. 77-78
A 75-year-old client diagnosed with dementia was found wandering a busy street and brought to the emergency department by police. What is the most effective way for the nurse to implement holistic data collection?

Remain present with the client, but allow the police to conduct the primary interview.

Conduct interviews with the client, the police, and appropriate family members and neighbors.

Seek out an interpreter trained in conducting geriatric interviews to talk with the client and his family members.

Use at least one standardized rating scale from each category of psychiatric illness to screen for all possible diagnoses.
Conduct interviews with the client, the police, and appropriate family members and neighbors.

To implement holistic data collection, the nurse should conduct interviews with the client, the police, and any family members, neighbors, or other secondary sources who might have relevant information to aid in the assessment of the client's health. The nurse should prioritize the client's safety and ensure that he or she is in stable condition before the police conduct an interview, if necessary. An interpreter is unlikely to be required in this scenario. If the client has language barriers, a professional translator may be used. Only standardized rating scales relevant to this client should be used for evaluation and monitoring.

p. 77
What is the main purpose of the mental status evaluation (MSE)?

To monitor severity of depression

To assess current cognitive processes

To identify stressors and coping mechanisms

To differentiate physical- and somatic-based symptoms
To assess current cognitive processes

The main purpose of the MSE is to assess current cognitive processes. A number of standardized rating scales are used to evaluate and monitor the severity of depression. Identification of stressors and coping mechanisms occurs during the psychosocial assessment. Thorough physical and psychological health evaluations will differentiate physical- and somatic-based symptoms.

Test-Taking Tip: Avoid looking for an answer pattern or code. There may be times when four or five consecutive questions have the same letter or number for the correct answer.

p. 80
Which interventions are most appropriate for a basic level psychiatric mental health registered nurse (PMH-RN)?

Managing the milieu by selecting activities for an adolescent group

Conducting a couples psychotherapy group focusing on effective parenting

Assisting a client's family in identifying appropriate housing for their parent

Presenting information on the special needs of the depressed to a family support group
-Managing the milieu by selecting activities for an adolescent group
-Assisting a client's family in identifying appropriate housing for their parent
-Presenting information on the special needs of the depressed to a family support group

The interventions that are appropriate for a PMH-RN to implement include milieu management with the selection of activities for an adolescent group, assisting a client's family in identifying appropriate housing for his or her parent, and presenting information on the special needs of depressed people to a family support group. Conducting a couples' psychotherapy group focusing on effective parenting is incorrect, because it is a prescriptive treatment that can only be performed by a psychiatric mental health advanced practice registered nurse.

p. 86
Which rating scale is used in the evaluation and monitoring of schizophrenia?

Beck Inventory

Zung Self-Report Inventory

Global Deterioration Scale (GDS)

Scale for Assessment of Negative Symptoms (SANS)
Scale for Assessment of Negative Symptoms (SANS)

The Scale for Assessment of Negative Symptoms (SANS) is used in the evaluation and monitoring of schizophrenia. The Beck Inventory and Zung Self-Report Inventory are used in depression. The Global Deterioration Scale (GDS) is used to evaluate and monitor cognitive function.

Test-Taking Tip: Sometimes the reading of a question in the middle or toward the end of an exam may trigger your mind with the answer or provide an important clue to an earlier question.

p. 82
Recommended textbook explanations

Fundamentals of Nursing

9th EditionAmy Hall, Anne Griffin Perry, Patricia A Potter, Patricia Stockert
873 explanations

Delivering Health Care in America

7th EditionDouglas Singh, Leiyu Shi
234 explanations

Dunmore and Fleischer's Medical Terminology Exercise in Eytmology

3rd EditionCharles W Dunmore, Cheryl Walker-Esbaugh, Laine H McCarthy, Rhonda A Sparks, Rita M Fleischer
1,985 explanations

The Human Body in Health and Disease

6th EditionGary A. Thibodeau, Kevin T. Patton
1,861 explanations