ATI RN
Behavioral Health Nursing Care Plans Questions
Question 1 of 5
A nurse is concerned that an agency’s policies are inadequate Which understanding about the relationship between substandard institutional policies and individual nursing practice should guide nursing practice?
Correct Answer: A
Rationale: In the context of behavioral health nursing care plans, it is crucial for nurses to understand the relationship between institutional policies and individual nursing practice. The correct answer is A) Agency policies do not exempt an individual nurse of responsibility to practice according to professional standards of nursing care. This understanding is essential because it emphasizes that regardless of institutional policies, nurses are ultimately accountable for practicing in accordance with the professional standards of nursing care. Nurses have a duty to advocate for their patients and ensure the provision of safe and effective care, even if institutional policies are lacking or inadequate. Option B is incorrect because while agency policies provide a framework for practice, they should not override the professional standards of care set by the nursing profession. Nurses must adhere to both legal and ethical standards in their practice. Option C is incorrect as discontinuing patient care immediately without following appropriate channels for addressing concerns may not be in the best interest of the patient or the nurse. Nurses should first inform their supervisor and work within the organization to address policy concerns. Option D is incorrect because nurses cannot rely on the judicial system to interpret policies on an individual basis. Instead, nurses should be proactive in addressing substandard policies within their healthcare institutions to ensure the delivery of high-quality care. In an educational context, this question highlights the importance of professional accountability, ethical decision-making, and advocating for patients in the face of substandard institutional policies. It underscores the need for nurses to prioritize patient safety and quality care above institutional policies while also working collaboratively within the healthcare team to address policy concerns.
Question 2 of 5
The desired outcome for a patient experiencing insomnia is, 'Patient will sleep for a minimum of hours nightly within days' At the end of days, review of sleep data shows the patient sleeps an average of hours nightly and takes a -hour afternoon nap The nurse will document the outcome as:
Correct Answer: D
Rationale: The correct answer is D) never demonstrated. In this scenario, the patient did not meet the desired outcome of sleeping for a minimum number of hours nightly within the specified time frame. The patient's average nightly sleep falls short of the goal, and the additional afternoon nap suggests poor sleep quality or inadequate sleep consolidation during the night. Option A) consistently demonstrated, is incorrect because the patient did not consistently achieve the desired outcome. Option B) often demonstrated, is incorrect because the patient did not often achieve the desired outcome. Option C) sometimes demonstrated, is incorrect because the patient did not occasionally achieve the desired outcome. From an educational perspective, understanding how to accurately assess and document patient outcomes is crucial in nursing care planning. By selecting the correct answer, nurses can provide an accurate representation of the patient's progress and adjust the care plan accordingly to promote better health outcomes. It is important for nurses to recognize when goals are not met so that appropriate interventions can be implemented to address any barriers to achieving desired outcomes.
Question 3 of 5
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?
Correct Answer: B
Rationale: Assessing cognition involves evaluating a patient’s judgment and decision-making abilities. This question tests the patient’s ability to reason and respond appropriately to a hypothetical health scenario. A rational response like 'Call my doctor' indicates intact cognition, while poor judgment (e.g., 'I’d wait and see') suggests impairment. Options A, C, and D assess different aspects: behavior (observable actions), affect/mood (emotional state), and perceptual disturbances (hallucinations), none of which are directly tested by this question.
Question 4 of 5
The nurse records this entry in a patients progress notes: Patient escorted to unit by ER nurse at 2130. Patients clothing was dirty. In interview room, patient sat with hands over face, sobbing softly. Did not acknowledge nurse or reply to questions. After several minutes, abruptly arose, ran to window, and pounded. Shouted repeatedly, Let me out of here. Verbal intervention unsuccessful. Order for stat dose 2 mg haloperidol PO obtained; medication administered at 2150. By 2215, patient stopped shouting and returned to sit wordlessly in chair. Patient placed on one-to-one observation. How should this documentation be evaluated?
Correct Answer: D
Rationale: The correct answer is D) Meets standards. This documentation is thorough and follows the standards of clear, concise, and accurate progress notes in behavioral health nursing. It includes relevant information about the patient's behavior, interventions, and outcomes, which is crucial for continuity of care and communication among the healthcare team. Option A) Uses unapproved abbreviations is incorrect because the documentation does not contain any unapproved abbreviations. The abbreviations used are commonly accepted in healthcare settings. Option B) Contains subjective material is incorrect because the documentation presents objective observations of the patient's behavior and responses. It does not include personal opinions or interpretations. Option C) Too brief to be of value is incorrect because although the documentation is succinct, it provides essential information about the patient's condition, interventions, and outcomes within a short timeframe. In acute care settings, brevity combined with accuracy is key to efficient communication and decision-making. In an educational context, emphasizing the importance of clear and comprehensive documentation in nursing practice is crucial. It ensures effective communication, continuity of care, legal protection, and supports evidence-based practice. Encouraging students to practice documenting in a structured and standardized manner prepares them for professional practice and promotes patient safety and quality care delivery.
Question 5 of 5
The patient states that he is 14 trillion years old and created the world. The nurse documents this statement as an example of which type of thinking displayed by the patient?
Correct Answer: A
Rationale: A delusion is a fixed false belief not based in reality. Ideas of reference are client's inaccurate interpretation that general events are personally directed to him or her, such as hearing a speech on the news and believing the message had personal meaning. Word salad is flow of unconnected words that convey no meaning to the listener. Hallucinations are false sensory perceptions or perceptual experiences that do not really exist.