Question 1

A student nurse asks an instructor how best to develop nursing outcomes for clients. Which response by the instructor most accurately answers the student's question?

Accepted Answer

Developing nursing outcomes for clients should involve client collaboration and be based on client problems. This approach ensures that outcomes are realistic, achievable, and centered around the client's needs. While NIC can be a helpful resource, it is not the only or necessarily the best approach to developing outcomes. Copying outcomes from a textbook does not reflect the unique needs and goals of each individual client.

Question 2

Number the following nursing interventions as they would proceed through the steps of the nursing process.
________ Determine if an antianxiety medication is decreasing a client's stress.
________ Measure a client's vital signs and review past history.
________ Encourage deep breathing and teach relaxation techniques.
________ Aim, with client collaboration, for a seven-hour night's sleep.
________ Recognize and document the client's problem.

Accepted Answer

2, 5, 4, 3, 1.

Question 3

The following outcome was developed for a client: "Client will list five personal strengths by the end of day one." Which correctly written nursing diagnostic statement most likely generated the development of this outcome?

Accepted Answer

The nursing diagnostic statement that most likely generated the development of the outcome is "Altered self-esteem R/T years of emotional abuse AEB self-deprecating statements." This diagnostic statement suggests that the client has low self-esteem and may benefit from identifying personal strengths. The outcome of listing five personal strengths by the end of day one is specific and measurable, and it relates directly to improving the client's self-esteem. The other diagnostic statements are not directly related to the outcome or do not provide a clear rationale for developing the outcome.

Question 4

How should a nurse prioritize nursing diagnoses?

Accepted Answer

Prioritizing nursing diagnoses should be based on the severity and life-threatening potential of each diagnosis to ensure the safety and well-being of the patient.

Question 5

The following NANDA-I 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?

Accepted Answer

The client is receiving ECT and is diagnosed with Parkinsonism. ECT can cause seizures, which can lead to injury. Parkinsonism can cause tremors and balance problems, which can also lead to injury.

Question 6

Which of the following characteristics of accurately developed client outcomes should a nurse identify?

Accepted Answer

Client outcomes should be specific and measurable to evaluate progress effectively, and they should be realistically based on the client's capability to ensure they are achievable.

Question 7

What is being assessed when a nurse asks a client to identify name, date, residential address, and situation?

Accepted Answer

The nurse is assessing the client's orientation to person (name), time (date), and place (residential address), as well as situation to determine their mental status and cognitive functioning.

Question 8

A client diagnosed with schizophrenia is exhibiting nonverbal behaviors indicating that the client is hearing things that others do not. Which nursing diagnosis, which was recently removed from the NANDA-I list, still accurately reflects this client's problem?

Accepted Answer

The nursing diagnosis "Disturbed sensory perception" accurately reflects the client's problem of hearing things that others do not. This diagnosis was recently removed from the NANDA-I list, but it is still a relevant and appropriate diagnosis for this client.

Question 9

Which statement regarding nursing interventions should a nurse identify as accurate?

Accepted Answer

Nursing interventions are not independent from the treatment team's goals or solely directed by written physician orders. Instead, nursing interventions occur independently but in concert with overall treatment team goals. These interventions are individualized based on patient needs and are not always standardized by policies and procedures.

Question 10

A client has a nursing diagnosis of Insomnia R/T paranoid thinking AEB MNA, DFA, and daytime napping. Which is a correctly written and appropriate outcome for this client?

Accepted Answer

C is the best choice because it is specific, measurable, and addresses the client's insomnia directly. It also sets a realistic time frame for improvement. Choices A and B may be helpful interventions, but they do not directly address the client's insomnia. Choice D is too vague and does not provide a clear objective for the client's progress.

Question 11

A _________________ __________________ provides the basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability.

Accepted Answer

The answer of A _________________ __________________ provides the basis for...

Question 12

Which statement is most accurate regarding the assessment of clients diagnosed with psychiatric problems?

Accepted Answer

Assessment of clients with psychiatric problems should provide a holistic view, including biopsychosocial aspects. Medical history is important in this assessment. Comprehensive assessments can be performed by all qualified nurses with appropriate training and education. Psychosocial evaluations should include both subjective reports and objective observations.

Question 13

The nurse should recognize which acronym as representing problem-oriented charting?

Accepted Answer

SOAPIE stands for Subjective, Objective, Assessment, Plan, Intervention, and Evaluation, which is a format used in problem-oriented charting.

Question 14

Within the nurse's scope of practice, which function is exclusive to the advanced practice psychiatric nurse?

Accepted Answer

Psychotherapy is within the scope of practice for advanced practice psychiatric nurses, but not for nurses without advanced training and certification. Teaching about side effects of medication, using milieu therapy, and providing case management are all within the scope of practice for both psychiatric nurses and advanced practice psychiatric nurses.

Question 15

What is the purpose of a nurse gathering client information?

Accepted Answer

The purpose of a nurse gathering client information is to make sound clinical judgments and plan appropriate care. This includes gaining an understanding of the client's medical history, current medical concerns, medications, lifestyle, and psychosocial history. This information allows the nurse to plan and provide appropriate care to meet the client's needs.

Question 16

Which tool would be appropriate for a nurse to use when assessing mental acuity prior to and immediately following electroconvulsive therapy (ECT)?

Accepted Answer

The Mini-Mental State Examination (MMSE) is a widely used tool to assess cognitive function and mental acuity. It is appropriate for the assessment of patients before and immediately following electroconvulsive therapy (ECT). It evaluates orientation, registration, attention and calculation, recall, language, and visual-spatial skills. It is a useful tool for monitoring cognitive changes after ECT.

Question 17

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?

Accepted Answer

The role of a milieu manager involves the implementation of interventions to maintain a therapeutic environment for clients, scheduling activities, and interacting with clients. This is particularly important in an inpatient psychiatric unit, where a safe and structured environment can support clients in their recovery. While health teaching, case management, and psychotherapy are also important roles for psychiatric nurses, they do not specifically address the maintenance of the therapeutic milieu.

Quiz 7: The Nursing Process in Psychiatricmental Health Nursing