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C assess the patients weight determine foods and

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c.Assess the patient’s weight; determine foods and amounts eaten.d.Arrange hospitalization for the patient in order to formulate a new treatment plan.ANS: CAssessment of biopsychosocial needs and general ability to live in the community is calledfor before any other action is taken. Both nutritional status and income adequacy are criticalassessment parameters. A patient may be able to maintain adequate nutrition while eatingonly one meal a day. The rule is toassess before taking action. Hospitalization may not benecessary. Smoking cessation strategies can be pursued later.PTS:1DIF:Cognitive Level: Apply (Application)REF:Pages 4-9, 17, 18TOP: Nursing Process: AssessmentMSC: Client Needs: Physiological Integrity8.A nurse surveys medical records. Which finding signals a violation of patients’ rights?a.A patient was not allowed to have visitors.b.A patient’s belongings were searched at admission.c.A patient with suicidal ideation was placed on continuous observation.d.Physical restraint was used after a patient was assaultive toward a staff member.ANS: AThe patient has the right to have visitors. Inspecting patients’ belongings is a safetymeasure. Patients have the right to a safe environment, including the right to be protectedagainst impulses to harm self.PTS:1DIF:Cognitive Level: Apply (Application)REF:Pages 4-21, 48 (Box 4-2)TOP: Nursing Process: EvaluationMSC: Client Needs: Safe, Effective Care Environment9.Which principle has the highest priority when addressing a behavioral crisis in an inpatientsetting?eBay: testbanks_and_xanaxeBay: testbanks_and_xanax
a.Resolve the crisis with the least restrictive intervention possible.b.Swift intervention is justified to maintain the integrity of a therapeutic milieu.c.Rights of an individual patient are superseded by the rights of the majority ofpatients.d.Patients should have opportunities to regain control without intervention if thesafety of others is not compromised.ANS: AThe rule of using the least restrictive treatment or intervention possible to achieve thedesired outcome is the patient’s legal right. Planned interventions are nearly alwayspreferable. Intervention may be necessary when the patient threatens harm to self.PTS:1DIF:Cognitive Level: Apply (Application)REF:Pages 4-21, 23, 24, 48 (Box 4-2)TOP: Nursing Process: ImplementationMSC: Client Needs: Safe, Effective Care Environment10.Clinical pathways are used in managed care settings toa.stabilize aggressive patients.b.identify obstacles to effective care.c.relieve nurses of planning responsibilities.d.streamline the care process and reduce costs.ANS: DClinical pathways provide guidelines for assessments, interventions, treatments, andoutcomes as well as a designated timeline for accomplishment. Deviations from the timelinemust be reported and investigated. Clinical pathways streamline the care process and savemoney. Care pathways do not identify obstacles or stabilize aggressive patients. Staff areresponsible for the necessary interventions. Care pathways do not relieve nurses of theresponsibility of planning; pathways may, however, make the task easier.

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