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Homework answers / question archive / Chapter 9: The Nursing Process in Psychiatric/Mental Health Nursing Multiple Choice Identify the choice that best completes the statement or answers the question
Chapter 9: The Nursing Process in Psychiatric/Mental Health Nursing
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1) Which data gathering technique is employed during the assessment phase of the nursing process?
|
A. |
Asking the client to rate mood after administering an antidepressant |
|
B. |
Asking the client to verbalize understanding of previously explained unit rules |
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C. |
Asking the client to describe any thoughts of self-harm |
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D. |
Asking the client if the group on assertiveness skills was helpful |
____ 2. Which statement is most accurate regarding the assessment of clients diagnosed with psychiatric problems?
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A. |
Medical history is of little significance and can be eliminated from the nursing assessment. |
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B. |
Assessment provides a holistic view of the client including biopsychosocial aspects. |
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C. |
Comprehensive assessments can be performed only by advanced practice nurses. |
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D. |
Psychosocial evaluations are gained by subjective reports rather than objective observations. |
____ 3. Which nursing diagnosis should a nurse identify as being correctly formulated?
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A. |
Schizophrenia R/T biochemical alterations AEB altered thought |
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B. |
Self-care deficit: hygiene R/T altered thought as AEB disheveled appearance |
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C. |
Depressed mood R/T multiple life stressors |
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D. |
Developmental disability R/T early-onset schizophrenia AEB hallucinations |
____ 4. Which expected client outcome should a nurse identify as being correctly formulated?
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A. |
Client will feel happier by discharge. |
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B. |
Client will demonstrate two relaxation techniques. |
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C. |
Client will verbalize triggers to anger by end of session. |
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D. |
Client will initiate interaction with one peer during free time within 2 days. |
____ 5. Which statement regarding nursing interventions should a nurse identify as accurate?
|
A. |
Nursing interventions are independent from the treatment team’s goals. |
|
B. |
Nursing interventions are solely directed by written physician orders. |
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C. |
Nursing interventions occur independently but in concert with overall treatment team goals. |
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D. |
Nursing interventions are standardized by policies and procedures. |
____ 6. Within the nurse’s scope of practice, which function is exclusive to the advance practice psychiatric nurse?
|
A. |
Teaching about the side effects of neuroleptic medications |
|
B. |
Using psychotherapy to improve mental health status |
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C. |
Using milieu therapy to structure a therapeutic environment |
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D. |
Providing case management to coordinate continuity of health services |
____ 7. A nurse charts “Verbalizes understanding of the side effects of Prozac.” This is an example of which category of focused charting?
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A. |
Data |
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B. |
Problem |
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C. |
Action |
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D. |
Response |
____ 8. The nurse should recognize which acronym as representing problem-oriented charting?
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A. |
SOAPIE |
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B. |
APIE |
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C. |
DAR |
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D. |
PQRST |
____ 9. Which tool would be appropriate for a nurse to use when assessing mental acuity prior to and immediately following electroconvulsive therapy (ECT)?
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A. |
CIWA scale |
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B. |
GGT |
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C. |
MMSE |
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D. |
CAPS scale |
____ 10. What is being assessed when a nurse asks a client to identify name, date, residential address, and situation?
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A. |
Mood |
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B. |
Perception |
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C. |
Orientation |
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D. |
Affect |
____ 11. What is the purpose when a nurse gathers client information?
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A. |
It enables the nurse to modify client behaviors related to personality disorders. |
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B. |
It enables the nurse to make sound clinical judgments and plan appropriate client care. |
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C. |
It enables the nurse to prescribe the appropriate medications. |
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D. |
It enables the nurse to assign the appropriate Axis I diagnosis. |
____ 12. A nurse on an inpatient psychiatric unit implements care by scheduling client activities, interacting with clients, and maintaining a safe therapeutic environment. These actions reflect which role of the nurse?
|
A. |
Health teacher |
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B. |
Case manager |
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C. |
Milieu manager |
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D. |
Psychotherapist |
____ 13. The following outcome was developed for a client: “Client will list five personal strengths by the end of day 1.” Which correctly written nursing diagnostic statement most likely generated the development of this outcome?
|
A. |
Altered self-esteem R/T years of emotional abuse AEB self-deprecating statements |
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B. |
Self-care deficit R/T altered thought processes |
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C. |
Disturbed body image R/T major depressive disorder AEB mood rating of 2/10 |
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D. |
Risk for disturbed self-concept R/T hopelessness AEB suicide attempt |
____ 14. How should a nurse prioritize nursing diagnoses?
|
A. |
By the established goal of care |
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B. |
By the life-threatening potential |
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C. |
By the physician’s priority of care |
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D. |
By the client’s preference |
____ 15. A client has a nursing diagnosis of Insomnia R/T paranoid thinking AEB midnight awakenings, difficulty falling asleep, and daytime napping. Which is a correctly written and appropriate outcome for this client’s problem?
|
A. |
The client will avoid daytime napping and attend all groups. |
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B. |
The client will exercise, as needed, before bedtime. |
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C. |
The client will sleep 7 uninterrupted hours by day four of hospitalization. |
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D. |
The client’s sleep habits will improve during hospitalization. |
____ 16. The following North American Nursing Diagnosis Association (NANDA) nursing diagnostic stem was developed for a client on an inpatient unit: Risk for injury. What assessment data most likely led to the development of this problem statement?
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A. |
The client is receiving electroconvulsive therapy (ECT) and is diagnosed with Parkinsonism. |
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B. |
The client has a history of four suicide attempts in adolescence. |
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C. |
The client expresses hopelessness and helplessness and isolates self. |
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D. |
The client has disorganized thought processes and delusional thinking. |
____ 17. A student nurse asks an instructor how best to develop nursing outcomes for clients. Which reply by the instructor most accurately answers the student’s question?
|
A. |
“Use the Nursing Interventions Classification (NIC) as a reference for nursing outcomes.” |
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B. |
“Look at your client’s problems and set a realistic, achievable goal.” |
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C. |
“Use the Nursing Outcomes Classification (NOC) as a reference for nursing outcomes.” |
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D. |
“Copy your standard outcomes from a nursing care plan textbook.” |
____ 18. A client diagnosed with schizophrenia is exhibiting nonverbal behaviors indicating that the client is hearing things that others do not. Which nursing diagnosis accurately reflects this client’s problem?
|
A. |
Altered thought processes |
|
B. |
Altered sensory perception |
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C. |
Anxiety |
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D. |
Chronic confusion |
____ 19. A nurse is evaluating the effectiveness of teaching after instructing a group of clients on joint replacement. In the evaluation step of the nursing process, which learning domain is the most difficult to measure?
|
A. |
Normative domain |
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B. |
Affective domain |
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C. |
Cognitive domain |
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D. |
Psychomotor domain |
____ 20. A client is recovering from abdominal surgery. In order to maximize the learning process prior to discharge teaching, which assessment should be performed by the nurse?
|
A. |
Assessing the client’s level of pain |
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B. |
Assessing and documenting the client’s vital signs |
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C. |
Assessing skin turgor and hydration status |
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D. |
Assessing incisional site for serosanguineous drainage |
____ 21. During the implementation phase of the nursing process, a nurse is teaching an adult with a cochlear implant about medications. Which modification in the teaching plan would be the most appropriate for this client?
|
A. |
Using repetition |
|
B. |
Speaking directly face-to-face |
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C. |
Employing the use of sign language |
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D. |
Providing large-print materials |
____ 22. A client who has slept 6 hours the previous night reports this to the assigned psychiatric nurse. What should be the initial nursing action to address this situation?
|
A. |
Provide warm milk and a backrub. |
|
B. |
Give a sleep medication. |
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C. |
Hold a relaxation group before bedtime. |
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D. |
Review the client’s normal sleep pattern. |
____ 23. An instructor overhears a student say, “That family seems to disagree more than agree. The family seems to be dysfunctional.” To further assess the family’s situation, which would be an appropriate instructor reply?
|
A. |
“Families who disagree can be a challenge to the treatment team.” |
|
B. |
“You seem very critical of the family. Do you believe that you are unable to help them?” |
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C. |
“Let’s bring the family in for an educational session to improve their communication.” |
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D. |
“What appears to trigger family disagreements?” |
____ 24. Which nursing response would be appropriately used in the evaluation phase of the nursing process?
|
A. |
“If I were in your situation, I would not repeat a behavior that has caused problems.” |
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B. |
“What do you think needs changing, and what do you want to do differently?” |
|
C. |
“What exactly will it take to carry out your plan, and what else do you need to do?” |
|
D. |
“This new approach seems to work for you.” |
____ 25. A client diagnosed with major depressive disorder states, “Why should I keep trying to get a job? I mess up everything I do.” Which correctly written nursing diagnosis best reflects the content and mood themes in this client’s statement?
|
A. |
Hopelessness R/T poor job performance |
|
B. |
Risk for impaired adjustment R/T inadequate social skills AEB isolation |
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C. |
Altered role performance R/T the fear of failure AEB not seeking employment |
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D. |
Chronic low self-esteem R/T major depressive disorder AEB self-hatred |
____ 26. During an intake interview, which question would assist the nurse in gathering data about the client’s judgment?
|
A. |
“What brought you to the hospital? Do you know what day and season it is now?” |
|
B. |
“On a scale of 1 to 10, how would you rate your stress level?” |
|
C. |
“What does the phrase ‘a rolling stone gathers no moss’ mean to you?” |
|
D. |
“If you found a stamped, addressed envelope in the street, what would you do?” |
____ 27. An adolescent client has problems expressing anger appropriately. Which nursing statement would encourage the client to set realistic goals?
|
A. |
“What do you think needs to change about how you express anger?” |
|
B. |
“How did you feel after attending the anger management session?” |
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C. |
“On a scale of 1 to 10, please rate your current level of anger.” |
|
D. |
“What bothers you about the actions of others when you get angry?” |
____ 28. The nurse interviewed a client who was uncooperative, answered questions with minimal responses, and rarely made eye contact. Which is the most complete documentation of baseline data obtained during the interview?
|
A. |
“Appears uncooperative. Exhibits characteristics of depression.” |
|
B. |
“Maintains poor eye contact throughout interview process. Unable to answer interview questions due to depression.” |
|
C. |
“States, ‘I don’t need to be here.’ when discussing admission status. Maintains minimal eye contact and offers little data related to triggers for admission.” |
|
D. |
“Unwilling to respond openly during interview.” |
____ 29. A client is assigned the nursing diagnosis of impaired social interaction R/T socio-cultural differences AEB client stating, “Although I’d like to, I don’t join in because I don’t speak the language so good.” Which correctly written outcome addresses this client’s problem?
|
A. |
The client will collaborate with nursing staff to set specific goals by day 3. |
|
B. |
The client will participate in one group activity of choice by day 2. |
|
C. |
The client will express a desire to interact with others. |
|
D. |
The client will become increasingly independent by discharge. |
____ 30. The following clients are seen in the emergency department. The psychiatric unit has one remaining bed. The triage nurse should expect which client to be admitted?
|
A. |
The client who is experiencing tremors and has a need for medication adjustment |
|
B. |
The client who is experiencing anxiety and a sad mood after separation from spouse |
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C. |
The client who is a single parent and hears voices stating, “Kill your infant son” |
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D. |
The client who argued with her boyfriend and inflicted a superficial cut on her arm |
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 31. Which of the following nursing interventions fall within the standards of psychiatric–mental health clinical nursing practice for a nurse generalist? (Select all that apply.)
|
A. |
Assist clients to perform activities of daily living. |
|
B. |
Consult with other clinicians to provide services for clients and effect system change. |
|
C. |
Encourage clients to discuss triggers for relapse. |
|
D. |
Use prescriptive authority in accordance with state and federal laws. |
|
E. |
Educate families about signs and symptoms of alcohol dependence and withdrawal. |
____ 32. Which of the following characteristics of accurately developed client outcomes should a nurse identify? (Select all that apply.)
|
A. |
Client outcomes are specifically formulated by nurses. |
|
B. |
Client outcomes are not restricted by time frames. |
|
C. |
Client outcomes are specific and measurable. |
|
D. |
Client outcomes are realistically based on client capability. |
|
E. |
Client outcomes are formally approved by the psychiatrist. |
____ 33. After a comprehensive assessment, correctly written nursing diagnoses developed for psychiatric clients may include which of the following components? (Select all that apply.)
|
A. |
Medical judgments related to the psychiatric disorder |
|
B. |
Unmet client needs present at the moment |
|
C. |
Supporting data that validate the diagnosis |
|
D. |
Outcomes that will be targets for nursing interventions |
|
E. |
Statements of client problems of a functional nature |
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