Question 1

The psychiatric-mental health nurse is preparing to assess a patient who has been diagnosed with mental illness. What model will the nurse use for the framework of the patient's assessment?

Accepted Answer

1. In the psychiatric setting, nurses use a holistic model to collect information across the domains of wellness. The information collected informs care and forms the basis of the care planning process. This holistic model ensures that the nurse identifies physiological, psychological, sociological, spiritual, and cultural aspects of the patient's life and carefully examines how the current reason for presenting to treatment relates to and influences the patient's life.

Question 2

The nurse is using the nursing process to care for a patient with mental illness. At what point of the nurse-patient interaction will the nurse perform the assessment phase of the nursing process?

Accepted Answer

4. The first phase of the nursing process, assessment, may begin prior to the first face-to-face meeting with the patient and continues until the patient leaves the setting. Assessment occurs during the entire nurse-patient encounter and does not end at diagnosis or evaluation phases.

Question 3

When formulating a nursing diagnosis, on which element should the nurse focus? Select all that apply.

Accepted Answer

3. When formulating a nursing diagnosis, the nurse should not just focus tightly on the patient's disease or condition, but the nurse should focus on how the patient's disease or condition affects the patient's life and the patient's adaptation to the disease or condition. The severity of the patient's disease or its treatment is not the primary focus of the nursing diagnosis.
5. When formulating a nursing diagnosis, the nurse should not just focus tightly on the patient's disease or condition, but the nurse should focus on how the patient's disease or condition affects the patient's life and the patient's adaptation to the disease or condition. The severity of the patient's disease or its treatment is not the primary focus of the nursing diagnosis.

Question 4

The nurse is performing an assessment on a newly admitted patient. What questions will the nurse ask to assess the patient's biological domain? Select all that apply.

Accepted Answer

1. The biological domain assessment includes demographic information, physical and developmental health histories and status, and history of any substance use or abuse. Asking the patient's, age, cardiac history, and if the patient is experiencing any physical symptoms such as pain are all questions pertaining to the biological domain. Assessment of mental status and suicidal ideation are related to the psychological domain.
2. The biological domain assessment includes demographic information, physical and developmental health histories and status, and history of any substance use or abuse. Asking the patient's, age, cardiac history, and if the patient is experiencing any physical symptoms such as pain are all questions pertaining to the biological domain. Assessment of mental status and suicidal ideation are related to the psychological domain.
5. The biological domain assessment includes demographic information, physical and developmental health histories and status, and history of any substance use or abuse. Asking the patient's, age, cardiac history, and if the patient is experiencing any physical symptoms such as pain are all questions pertaining to the biological domain. Assessment of mental status and suicidal ideation are related to the psychological domain.

Question 5

The psychiatric-mental health nurse is using the nursing process when caring for a patient diagnosed with mental illness. What tasks may be accomplished during the evaluation phase of the nursing process? Select all that apply.

Accepted Answer

1. Evaluation is the process by which the nurse determines what progress has been made relevant to the plan of care. The result of this evaluation may include renegotiating needs to be addressed; identifying new, different, or additional goals and outcomes; and redefining the roles of the patient and nurse in achieving outcomes. Choosing appropriate interventions according to the patient assessment occurs during the implementation, not evaluation, stage of the nursing process.
2. Evaluation is the process by which the nurse determines what progress has been made relevant to the plan of care. The result of this evaluation may include renegotiating needs to be addressed; identifying new, different, or additional goals and outcomes; and redefining the roles of the patient and nurse in achieving outcomes. Choosing appropriate interventions according to the patient assessment occurs during the implementation, not evaluation, stage of the nursing process.
3. Evaluation is the process by which the nurse determines what progress has been made relevant to the plan of care. The result of this evaluation may include renegotiating needs to be addressed; identifying new, different, or additional goals and outcomes; and redefining the roles of the patient and nurse in achieving outcomes. Choosing appropriate interventions according to the patient assessment occurs during the implementation, not evaluation, stage of the nursing process.
5. Evaluation is the process by which the nurse determines what progress has been made relevant to the plan of care. The result of this evaluation may include renegotiating needs to be addressed; identifying new, different, or additional goals and outcomes; and redefining the roles of the patient and nurse in achieving outcomes. Choosing appropriate interventions according to the patient assessment occurs during the implementation, not evaluation, stage of the nursing process.

Question 6

What elements make up the nursing process? Select all that apply.

Accepted Answer

1. The nursing process includes the steps nurses use to identify needs for care; analyze, prioritize, and plan for intervention; and evaluate the nursing care that is delivered to patients. This is a process of assessment and problem solving that occurs jointly with patients. The nursing process includes assessment, diagnosis, planning, and evaluation. While communication is vitally important in providing nursing care, it is not a separate step of the nursing process.
2. The nursing process includes the steps nurses use to identify needs for care; analyze, prioritize, and plan for intervention; and evaluate the nursing care that is delivered to patients. This is a process of assessment and problem solving that occurs jointly with patients. The nursing process includes assessment, diagnosis, planning, and evaluation. While communication is vitally important in providing nursing care, it is not a separate step of the nursing process.
3. The nursing process includes the steps nurses use to identify needs for care; analyze, prioritize, and plan for intervention; and evaluate the nursing care that is delivered to patients. This is a process of assessment and problem solving that occurs jointly with patients. The nursing process includes assessment, diagnosis, planning, and evaluation. While communication is vitally important in providing nursing care, it is not a separate step of the nursing process.
4. The nursing process includes the steps nurses use to identify needs for care; analyze, prioritize, and plan for intervention; and evaluate the nursing care that is delivered to patients. This is a process of assessment and problem solving that occurs jointly with patients. The nursing process includes assessment, diagnosis, planning, and evaluation. While communication is vitally important in providing nursing care, it is not a separate step of the nursing process.

Question 7

The nurse is performing an admitting assessment on a patient who has been diagnosed with depression. What is the purpose of this process?

Accepted Answer

2. Assessments performed on admission allow the nurse to identify patient information and history. While establishing a therapeutic nurse-patient relationship, determining mutual goals of care, and establishing and documenting the nursing diagnosis are important interventions, they are not the purpose of the admitting assessment.

Question 8

The nurse is planning care for a patient with mental illness. When formulating the patient's nursing diagnosis, what elements will the nurse include? Select all that apply.

Accepted Answer

1. The three aspects of the nursing diagnosis include: Naming the problem, providing data that shows evidence of the problem or the signs and symptoms present, and the etiology of the problem. The nursing diagnosis does not identify the disease or disorder; rather, the nursing diagnosis identifies problems evidenced by clinical symptoms. The nursing diagnosis does not provide intervention.
2. The three aspects of the nursing diagnosis include: Naming the problem, providing data that shows evidence of the problem or the signs and symptoms present, and the etiology of the problem. The nursing diagnosis does not identify the disease or disorder; rather, the nursing diagnosis identifies problems evidenced by clinical symptoms. The nursing diagnosis does not provide intervention.
5. The three aspects of the nursing diagnosis include: Naming the problem, providing data that shows evidence of the problem or the signs and symptoms present, and the etiology of the problem. The nursing diagnosis does not identify the disease or disorder; rather, the nursing diagnosis identifies problems evidenced by clinical symptoms. The nursing diagnosis does not provide intervention.

Question 9

The psychiatric-mental health nurse is receiving a report on a patient being transferred to the hospital from a local emergency department. What is important for the receiving nurse to remember during this pre-interaction with the patient?

Accepted Answer

2. Obtaining report on a patient occurs during the pre-interaction phase of a nursing assessment. It is important for the receiving nurse to suspend expectations about the patient, as these expectations or perceptions may cause the nurse to prejudge the patient prior to the patient-nurse interaction. The nurse should always reflect on a patient's condition, as reflecting is used as a therapeutic tool in the nurse-patient relationship. The nurse will not determine the patient's state of mind or how the patient will present prior to meeting with the patient, as these actions prejudge the patient prior to the initial nurse-patient interaction.

Question 10

What is an advantage of the nursing diagnosis over the DSM diagnosis for the patient diagnosed with a mental illness?

Accepted Answer

4. An advantage of the nursing diagnosis is that it is more detailed and specific to each individual than the DSM diagnosis. The nursing diagnosis is not more accurate, general, or effective than the DSM diagnosis.

Question 11

The nurse is caring for a patient who may have dementia. What will the nurse assess when conducting a mental status examination? Select all that apply.

Accepted Answer

1. Aspects of a mental status examination include the patient's attitude, cognitive functioning, speech, and emotional status. A mental status exam does not include substance use assessment.
2. Aspects of a mental status examination include the patient's attitude, cognitive functioning, speech, and emotional status. A mental status exam does not include substance use assessment.
3. Aspects of a mental status examination include the patient's attitude, cognitive functioning, speech, and emotional status. A mental status exam does not include substance use assessment.
5. Aspects of a mental status examination include the patient's attitude, cognitive functioning, speech, and emotional status. A mental status exam does not include substance use assessment.

Question 12

The nurse is assessing a patient who has been diagnosed with a major mental health disorder. The nurse has decided that using a timeline would be beneficial when assessing the patient. What is true regarding the use of a timeline? Select all that apply.

Accepted Answer

2. One way to involve the patient actively in providing historical information during assessment is to start a timeline with the patient. As patients reflect on important events and experiences, they gain perspective on difficulties and problems that have not been resolved. This process may lead to important insights that can be discussed in treatment. In addition, a timeline in the patient's record can also offer important background information to the clinician. A timeline can be used to denote significant events across the life span. The timeline not only serves an assessment function, but it may also serve as an intervention. The timeline does not, however, evaluate nursing interventions.
3. One way to involve the patient actively in providing historical information during assessment is to start a timeline with the patient. As patients reflect on important events and experiences, they gain perspective on difficulties and problems that have not been resolved. This process may lead to important insights that can be discussed in treatment. In addition, a timeline in the patient's record can also offer important background information to the clinician. A timeline can be used to denote significant events across the life span. The timeline not only serves an assessment function, but it may also serve as an intervention. The timeline does not, however, evaluate nursing interventions.
4. One way to involve the patient actively in providing historical information during assessment is to start a timeline with the patient. As patients reflect on important events and experiences, they gain perspective on difficulties and problems that have not been resolved. This process may lead to important insights that can be discussed in treatment. In addition, a timeline in the patient's record can also offer important background information to the clinician. A timeline can be used to denote significant events across the life span. The timeline not only serves an assessment function, but it may also serve as an intervention. The timeline does not, however, evaluate nursing interventions.
5. One way to involve the patient actively in providing historical information during assessment is to start a timeline with the patient. As patients reflect on important events and experiences, they gain perspective on difficulties and problems that have not been resolved. This process may lead to important insights that can be discussed in treatment. In addition, a timeline in the patient's record can also offer important background information to the clinician. A timeline can be used to denote significant events across the life span. The timeline not only serves an assessment function, but it may also serve as an intervention. The timeline does not, however, evaluate nursing interventions.

Question 13

The nurse is caring for a patient with mental illness. What will the nurse assess during the cognitive function portion of the patient exam? Select all that apply.

Accepted Answer

1. The cognitive portion of the mental status exam includes assessment of the patient's state of consciousness, memory, and judgment. Emotional status and thought processes are separate areas of the mental status exam, not part of the cognitive function portion of the mental status exam.
2. The cognitive portion of the mental status exam includes assessment of the patient's state of consciousness, memory, and judgment. Emotional status and thought processes are separate areas of the mental status exam, not part of the cognitive function portion of the mental status exam.
5. The cognitive portion of the mental status exam includes assessment of the patient's state of consciousness, memory, and judgment. Emotional status and thought processes are separate areas of the mental status exam, not part of the cognitive function portion of the mental status exam.

Question 14

The nurse is conducting a mental status exam on a patient with suspected dementia. How will the nurse assess the patient's fund of general information?

Accepted Answer

2. To assess the patient's general fund of information, the nurse will ask the patient the name of the president. Asking the patient what year it is assesses the patient's orientation. Asking the patient to spell the word 'world' both forward and backward assesses the patient's attention and concentration. Asking the patient to interpret a known proverb assess the patient's abstraction capacity.

Question 15

During the assessment of a patient with a major psychiatric disorder, the nurse learns that the patient's mother has the same disorder. What domain is the nurse using to assess the patient?

Accepted Answer

3. Assessment of the patient's family, work, and social history can provide information essential to developing the plan of care. This information is part of the sociological domain. While the other answer choices are assessment domains, they do not focus on family history.

Question 16

What is identified in the second portion of the nursing diagnosis?

Accepted Answer

2. The nursing diagnosis is broken up into three separate sections. The second portion of the nursing diagnosis identifies the nurse's assessment of the cause, or etiology, of the problem. The first portion of the nursing diagnosis identifies the focal pattern, problem, or behavior that is observed. The third portion of the nursing diagnosis identifies the evidence or data that indicate or support the problem statement. The nursing diagnosis does not identify steps to resolve the problem.

Question 17

The nurse is caring for a patient with a major psychiatric disorder. The nurse notes that the patient's speech is rapid and incoherent at times. What domain is the nurse assessing?

Accepted Answer

4. Assessment of the patient's speech, including quantity, quality, and organization of speech, is part of the psychological domain. While the other answer choices are assessment domains, they do not focus on the assessment of the patient's speech.

Question 18

The nurse is conducting a mental status exam on a patient with schizophrenia. The patient reveals to the nurse that he hears voices in his head. What is the nurse's priority assessment?

Accepted Answer

2. The patient is experiencing auditory hallucinations. The nurse's priority is to determine if the hallucinations are command hallucinations, which may place the patient in danger of harming himself or others. The nurse's priority is not to determine if the hallucinations are fantasy-oriented. While the nurse will assess if the patient has a disturbance in thought process and orientation, these are not the most important things for the nurse to assess regarding the patient's symptoms.

Question 19

Which nursing intervention best supports the concept that the nursing process is dynamic in nature?

Accepted Answer

4. The dynamic, ever-changing nature of the nursing process is best demonstrated when the nurse frequently re-addresses patient interventions after any status change in the patient's status. While the other interventions are appropriate nursing interventions, these do not demonstrate the dynamic nature of the nursing process.

Question 20

The nurse is caring for a patient with early-onset dementia. What statement made by the nurse best assesses the patient's abstraction capacity?

Accepted Answer

4. Assessing the patient's abstraction capacity utilizes the psychological domain. The best way for the nurse to assess the patient's abstraction capacity is to ask the patient to state the meaning of a popular proverb. The nurse will then assess the way the patient interprets the proverb (literal, concrete, abstract, incoherent). Asking the patient to spell the word 'world' forward or backward assesses the patient's attention and concentration. Asking the patient to state the president's name assesses the patient's general fund of information. Asking the patient to state his or her name, the date, and the patient's location assesses the patient's orientation.

Quiz 9: The Nursing Process in Psychiatric-Mental Health Nursing