MENTAL HESI EXAM QUESTIONS & ANSWERS1. A nurse is a member of an interdisciplinary team that uses critical pathways. According to the
critical pathway,
... [Show More] on day 2 of the hospital stay, the patient should be sitting in the chair. It is day 3,
and the patient cannot sit in the chair. What should the nurse do?
a. Add this data to the problem list.
b. Focus chart using the DAR format.
c. Document the variance in the patient’s record.
d. Report a positive variance in the next interdisciplinary team meeting.
ANS: C
A variance occurs when the activities on the critical pathway are not completed as predicted or the
patient does not meet expected outcomes. An example of a negative variance is when a patient develops
pulmonary complications after surgery, requiring oxygen therapy and monitoring with pulse oximetry. A
positive variance occurs when a patient progresses more rapidly than expected (e.g., use of a Foley
catheter may be discontinued a day early). When a nurse is using the problem-oriented medical record,
after analyzing data, health care team members identify problems and make a single problem list. A third
format used for notes within a POMR is focus charting. It involves the use of DAR notes, which include
D—Data (both subjective and objective), A— Action or nursing intervention, and R—Response of the
patient (i.e., evaluation of effectiveness).
2. A nurse needs to begin discharge planning for a patient admitted with pneumonia and a congested
cough. When is the best time the nurse should start discharge planning for this patient?
a. Upon admission
b. Right before discharge
c. After the congestion is treated
d. When the primary care provider writes the order
ANS: A
Ideally, discharge planning begins at admission. Right before discharge is too late for discharge planning.
After the congestion is treated is also too late for discharge planning. Usually the primary care provider
writes the order too close to discharge, and nurses do not need an order to begin the teaching that will be
needed for discharge. By identifying discharge needs early, nursing and other health care professionals
begin planning for discharge to the appropriate level of care, which sometimes includes support services
such as home care and equipment needs.
3. A patient is being discharged home. Which information should the nurse include?
a. Acuity level
b. Community resources
c. Standardized care plan
d. Signature for verbal order
ANS: B
Discharge documentation includes medications, diet, community resources, follow-up care, and who to
contact in case of an emergency or for questions. A patient’s acuity level, usually determined by a
computer program, is based on the types and numbers of nursing interventions (e.g., intravenous [IV]
therapy, wound care, or ambulation assistance) required over a 24-hour period. Many computerized
documentation systems include standardized care plans or clinical practice guidelines (CPGs) to
facilitate the creation and documentation of a nursing and or interprofessional plan of care. Each CPG
facilitates safe and consistent care for an identified problem by describing or listing institutional
standards and evidence-based guidelines that are easily accessed and included in a patient’s electronic
health record. Verbal orders occur when a health care provider gives therapeutic orders to a registered
nurse while they are standing in proximity to one another.
4. A nurse developed the following discharge summary sheet. Which critical information should the
nurse add?
1
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