During the assessment phase of the nursing process, data collection takes place. What methods does the nurse employ to gather data? (Select all that apply.)

Reviewing diagnostic test results.

Interviewing the client and significant others.

Performing a physical assessment.

Interpreting the behaviors of the client.

Answer and Explanation

Correct Answer : A,B,C,D

Choice A rationale
Reviewing diagnostic test results is a crucial method for gathering data during the assessment phase of the nursing process. These results can provide valuable insights into the client’s health status and help to guide the planning and implementation of care.
Choice B rationale
Interviewing the client and significant others is another important method for data collection. This can help to gather information about the client’s symptoms, lifestyle, and personal history, which can all inform the care provided.
Choice C rationale
Performing a physical assessment is a key part of data collection in the nursing process. This involves examining the client’s physical condition and looking for any signs of illness or injury.
Choice D rationale
Interpreting the behaviors of the client is also a crucial part of data collection. This can provide insights into the client’s mental and emotional state, which can be particularly important in mental health nursing.

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Correct Answer is B

Explanation

Choice A rationale
While teaching the client techniques for coping with the mother’s anger might be helpful, it does not address the root cause of the problem. The mother’s anger and inappropriate responses could be due to frustration from not being able to hear properly.
Choice B rationale
The mother’s behavior of not responding when her back is turned and becoming increasingly angry could be signs of hearing loss. A hearing evaluation would help determine if this is the case and appropriate interventions can be put in place.
Choice C rationale
Telling the client that it appears the mother has a hearing loss is not the best intervention because it is based on assumption without any professional evaluation. It is important to have a professional evaluation before making such conclusions.
Choice D rationale
Informing the client to ignore the behavior and treat the mother with love does not address the potential issue of hearing loss. Ignoring the problem does not solve it and could lead to further frustration and misunderstanding.

A. Confusion. B. Dementia. C. Delirium. D. Aggression.

Correct Answer is B

Explanation

Choice A rationale
Confusion can cause a temporary state of disorientation and difficulty with concentration and memory, but it doesn’t typically result in a loss of multiple abilities such as short- and long- term memory, language, and the ability to understand.
Choice B rationale
Dementia is a progressive condition that affects memory, thinking skills, and the ability to perform everyday tasks. It can cause loss of multiple abilities such as short- and long-term memory, language, and the ability to understand.
Choice C rationale
Delirium is a sudden and severe confusion that comes on quickly and can cause changes in memory, thinking, attention, and perception. However, it is usually temporary and reversible, unlike the progressive loss of abilities seen in dementia.
Choice D rationale
Aggression is a type of behavior characterized by hostile, forceful, or destructive actions. It does not involve a loss of multiple abilities such as short- and long-term memory, language, and the ability to understand.

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During the assessment phase of the nursing process, data collection takes place. What methods does the nurse employ to gather data? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client reports to the nurse that her elderly mother has become increasingly angry and responds inappropriately to conversations within the past few months. She notes that her mother does not respond when the mother’s back is turned. What is the best intervention for the nurse?

Correct Answer is B

Explanation

The patient is experiencing loss of multiple abilities such as short- and long-term memory, language, and the ability to understand. What condition does the patient have?

Correct Answer is B

Explanation

Upon entrance into a mental health care system, clients are thoroughly assessed, and this is followed by the development of a mental health treatment plan assessment. Which of the following are purposes of the treatment plan? (Select all that apply)

During the mental status examination, the nurse observes that the client rapidly shifts from one idea to another related thought. Which disordered thinking process is the client displaying?

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The home health aide reports to the practical nurse that the client has been trying to give away possessions. When the nurse asks the client about this behavior, the client says, “With my spouse dead, there’s no reason for me to go on.”. What is the best priority response by the nurse?

A patient has been admitted due to severe depression. What symptoms should the nurse anticipate during the assessment?

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In communicating with the psychiatric patient, which nurse responses could obstruct effective communication with a client? (Select all that apply)