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

Question 1

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
B)Self-care deficit R/T altered thought processes
C)Disturbed body image R/T major depressive disorder AEB mood rating of 2/10
D)Risk for disturbed self-concept R/T hopelessness AEB suicide attempt

Answer 1

Altered self-esteem R/T years of emotional abuse AEB self-deprecating statements

Question 2

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

A)SOAPIE
B)SOLER
C)DAR
D)PQRST

Answer 2

SOAPIE

Question 3

Which expected client outcome should a nurse identify as being correctly formulated?

A)Client will feel happier by discharge.
B)Client will demonstrate two relaxation techniques.
C)Client will verbalize triggers to anger by end of session.
D)Client will initiate interaction with one peer during free time within 2 days.

Answer 3

Client will initiate interaction with one peer during free time within 2 days.

Question 4

Which nursing diagnosis should a nurse identify as being correctly formulated?

A)Schizophrenia R/T biochemical alterations AEB altered thought
B)Self-care deficit: hygiene R/T altered thought AEB disheveled appearance
C)Depressed mood R/T multiple life stressors
D)Developmental disability R/T early-onset schizophrenia AEB hallucinations

Question 5

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

A)CIWA scale
B)GGT
C)MMSE
D)CAPS scale

Question 6

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
C)Asking the client to describe any thoughts of self-harm
D)Asking the client if the group on assertiveness skills was helpful

Question 7

The following North American Nursing Diagnosis Association (NANDA)nursing diagnostic stem was developed for a client on an inpatient unit:"Risk for injury." Which assessment data most likely led to the development of this problem statement?

A)The client is receiving ECT and is diagnosed with Parkinsonism.
B)The client has a history of four suicide attempts in adolescence.
C)The client expresses hopelessness and helplessness and isolates self.
D)The client has disorganized thought processes and delusional thinking.

Question 8

Which is the nurse's purpose when gathering client information?

A)It enables the nurse to modify client behaviors related to personality disorders.
B)It enables the nurse to make sound clinical judgments and plan appropriate client care.
C)It enables the nurse to prescribe the appropriate medications.
D)It enables the nurse to assign the appropriate Axis I diagnosis.

Question 9

A student nurse asks an instructor which resource is best to use when developing nursing outcomes for clients.Which reply most accurately answers the student's question?

A)"Use the Nursing Interventions Classification (NIC)as a reference for nursing outcomes."
B)"Use the NANDA resource to identify appropriate outcomes."
C)"Use the Nursing Outcomes Classification (NOC)as a reference for nursing outcomes."
D)"Copy your standard outcomes from a nursing care plan textbook."

Question 10

Which function is exclusive to the advance practice psychiatric nurse's scope of practice?

A)Teaching about the side effects of neuroleptic medications
B)Using psychotherapy to improve mental health status
C)Using milieu therapy to structure a therapeutic environment
D)Providing case management to coordinate continuity of health services

Question 11

How should a nurse prioritize nursing diagnoses?

A)By the established goal of care
B)By the life-threatening potential
C)By the physician's priority of care
D)By the client's preference

Question 12

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

A)Medical history is of little significance and can be eliminated from the nursing assessment.
B)Assessment provides a holistic view of the client,including biopsychosocial aspects.
C)Comprehensive assessments can be performed only by advanced practice nurses.
D)Psychosocial evaluations are gained by subjective reports rather than objective observations.

Question 13

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.
B)The client will exercise,as needed,before bedtime.
C)The client will sleep 7 uninterrupted hours by day 4 of hospitalization.
D)The client's sleep habits will improve during hospitalization.

Question 14

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
C)Anxiety
D)Chronic confusion

Question 15

A nursing instructor is teaching students about the purpose of using the nursing process in the care of psychiatric patients.Which of the following statements by a student indicates learning has occurred?

A)"The nursing process is a method for interviewing the patient in a systematic way."
B)"The nursing process is used to assist patients to adapt successfully to stressors within the environment."
C)"The nursing process is used to provide support for the psychiatric diagnosis."
D)"The nursing process is used primarily to minimize allegations of negligence."

Question 16

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
B)Case manager
C)Milieu manager
D)Psychotherapist

Question 17

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

A)Mood
B)Perception
C)Orientation
D)Affect

Question 18

A nurse charts "Verbalizes understanding of the side effects of Prozac." This is an example of which category of focused charting?

A)Data
B)Problem
C)Action
D)Response

Question 19

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

A)Nursing interventions are independent of the treatment team's goals.
B)Nursing interventions are directed solely by written physician orders.
C)Nursing interventions occur independently but align with overall treatment team goals.
D)Nursing interventions are standardized by policies and procedures.

Question 20

A client is diagnosed with Generalized Anxiety Disorder.Which assessment should the nurse perform to maximize the learning process prior to discharge teaching?

A)Assess the client's level of anxiety.
B)Assess and document the client's vital signs.
C)Assess suicide risk.
D)Assess availability of support systems.

Question 21

During an intake interview,which question would best assist the nurse to gather 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?"

Question 22

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?"
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?"

Question 23

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
C)Altered role performance R/T the fear of failure AEB not seeking employment
D)Chronic low self-esteem R/T major depressive disorder AEB self-hatred

Question 24

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."

Question 25

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

Question 26

The following clients are seen in the emergency department.The psychiatric unit has one remaining bed.Which client should the triage nurse expect 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
C)The client who is a single parent and hears voices stating,"Kill your infant son."
D)The client who argued with her boyfriend and inflicted a superficial cut on her arm

Question 27

A client who slept 6 hours the previous night reports it to the assigned psychiatric nurse.Which should be the initial nursing action to address this situation?

A)Provide warm milk and a backrub.
B)Give a sleep medication.
C)Hold a relaxation group before bedtime.
D)Review the client's normal sleep pattern.

Question 28

Which nursing response best represents the evaluation phase of the nursing process?

A)"If I were in your situation,I would not repeat a behavior that has caused problems."
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)"It sounds like you're saying this new approach is working for you."

Question 29

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)Act as a consultant 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.

Question 30

A nursing 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 reply by the instructor?

A)"Families who disagree can be a challenge to the treatment team."
B)"You seem critical of the family.Do you believe that you are unable to help them?"
C)"Let's bring the family in for an educational session to improve their communication."
D)"What appears to trigger family disagreements?"

Question 31

During the implementation phase of the nursing process,a nurse is teaching an adult depressed patient with a cochlear implant about medications.Which modification in the teaching plan would be best for this client?

A)Using repetition
B)Speaking directly face to face
C)Employing the use of sign language
D)Providing large-print materials

Question 32

Which of the following are characteristics of accurately developed client outcomes? Select all that apply.

A)Client outcomes are formulated by each nurse independent of other team members.
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.

Question 33

A client is assigned the nursing diagnosis of impaired social interaction R/T sociocultural 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.