b. c. d. e.
The patient’s subjective responses Only data obtained from the patient’s verbal responses A description of the patient’s behavior during the interview Analysis of why the patient was unresponsive during the interview
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ANS: B, D Both content and process of the interview should be documented. Providing only the patient’s verbal responses would create a skewed picture of the patient. Writing that the patient was uncooperative is subjectively worded. An objective description of patient behavior would be preferable. Analysis of the reasons for the patient’s behavior would be speculation, which is inappropriate.
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PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Pages 7-24, 25, 40 (Table 7-4), 51 (Box 7-6) TOP: Nursing Process: Assessment MSC: Client Needs: Safe, Effective Care Environment
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2. A nurse performing an assessment interview for a patient with a substance use disorder decides to use a standardized rating scale. Which scales are appropriate? (Select all that apply.) a. Addiction Severity Index (ASI) b. Brief Drug Abuse Screen Test (B-DAST) c. Abnormal Involuntary Movement Scale (AIMS) d. Cognitive Capacity Screening Examination (CCSE) e. Recovery Attitude and Treatment Evaluator (RAATE)
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ANS: A, B, E Standardized scales are useful for obtaining data about substance use disorders. The ASI, B-DAST, and RAATE are scales related to substance abuse. AIMS assesses involuntary movements associated with antipsychotic medications. The CCSE assesses cognitive function.
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PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Pages 7-15, 34 (Table 7-1) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
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3. What information is conveyed by nursing diagnoses? (Select all that apply.) a. Medical judgments about the disorder b. Unmet patient needs currently present c. Goals and outcomes for the plan of care d. Supporting data that validate the diagnoses e. Probable causes that will be targets for nursing interventions ANS: B, D, E Nursing diagnoses focus on phenomena of concern to nurses rather than on medical diagnoses. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Pages 7-16, 17 TOP: Nursing Process: Diagnosis/Analysis MSC: Client Needs: Safe, Effective Care Environment
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