Deck 8: The Nursing Process and Standards of Care for Psychiatric Mental Health Nursing

Question 1

As a nurse assesses an elderly patient,answers seem vague or unrelated to the questions.The patient also leans forward and frowns,listening intently to the nurse.An appropriate question for the nurse to ask would be:

A) "Are you having difficulty hearing when I speak?"
B) "I notice you frowning.Are you feeling annoyed with me?"
C) "How can I make this assessment interview easier for you?"
D) "You're having trouble focusing on what I'm saying.What is distracting you?"

Answer 1

"Are you having difficulty hearing when I speak?"

Question 2

A nurse asks a patient,"If you had fever and vomiting for 3 days,what would you do?" Which aspect of the mental status examination is the nurse assessing?

A) Behavior
B) Cognition
C) Affect and mood
D) Perceptual disturbances

Answer 2

Cognition

Question 3

Which nursing documentation best meets the requirement for problem-oriented charting?

A) "Pacing and muttering to self.Sensory perceptual alteration related to internal auditory stimulation.Given fluphenazine 2.5 mg PO at 0900 and went to room to lie down.Calmer by 0930.Returned to lounge to watch TV."
B) "Agitated behavior.Patient muttering to self as though answering an unseen person.Given haloperidol 2 mg PO and went to room to lie down.Patient calmer within 30 minutes.Returned to lounge to watch TV."
C) "S: States 'I feel like I'm ready to blow up.' O: Pacing hall,mumbling to self.A: Auditory hallucinations.P: Offer haloperidol 2 mg PO.I: Haloperidol 2 mg PO given at 0900.E: Returned to lounge at 0930 and quietly watched TV."
D) "Pacing hall and muttering to self as though answering an unseen person.Haloperidol 2 mg PO administered at 0900,with calming effect in 30 minutes.Stated 'I'm no longer bothered by the voices.'"

Answer 3

"S: States 'I feel like I'm ready to blow up.' O: Pacing hall,mumbling to self.A: Auditory hallucinations.P: Offer haloperidol 2 mg PO.I: Haloperidol 2 mg PO given at 0900.E: Returned to lounge at 0930 and quietly watched TV."

Question 4

A patient begins a new program to assist with building social skills.In which part of the plan of care should a nurse record this item?
Encourage patient to attend one psychoeducational group daily.

A) Assessment
B) Analysis
C) Planning
D) Implementation
E) Evaluation

Question 5

A patient states: "I'm not worth anything.I have negative thoughts about myself.I want to go to sleep and never wake up." Which nursing intervention has the highest priority?

A) Self-esteem building activities
B) Anxiety self-control measures
C) Sleep enhancement activities
D) Suicide precautions

Question 6

Complete this nursing diagnosis: ___________ related to shyness and poorly developed social skills as evidenced by watching television alone at home every evening.

A) Ineffective individual coping
B) Deficient knowledge
C) Powerlessness
D) Social isolation

Question 7

Nursing behaviors associated with the implementation phase of the nursing process are concerned with:

A) carrying out interventions and coordinating care.
B) comparing patient responses and expected outcomes.
C) gathering accurate and sufficient patient-centered data.
D) participating in mutual identification of patient outcomes.

Question 8

Before assessing a new patient,a nurse is told by another health care worker,"I know that patient.No matter how hard we work,there isn't much improvement by the time of discharge." The nurse's responsibility is to:

A) document the other worker's assessment of the patient.
B) assess the patient based on data collected from all sources.
C) validate the worker's impression by contacting the patient's significant other.
D) discuss the worker's impression with the patient during the assessment interview.

Question 9

A patient's nursing diagnosis is sleep-pattern disturbance.The desired outcome is: Patient will sleep for a minimum of 5 hours nightly by October 31.On November 1,review of sleep data for 6 days shows the patient slept an average of 4 hours nightly and took 2-hour afternoon naps daily.Which evaluation should be documented?

A) Consistently demonstrated
B) Often demonstrated
C) Sometimes demonstrated
D) Never demonstrated

Question 10

A nurse works with a patient to establish outcomes but believes that one outcome suggested by the patient is not in the patient's best interests.What is the nurse's best action?

A) Remain silent.
B) Educate the patient that the outcome is not realistic.
C) Explore the consequences if the outcome is achieved.
D) Formulate an appropriate outcome without the patient's input.

Question 11

An adult patient recently diagnosed with cancer states,"I've lived my life according to the Bible.I don't understand why God has forsaken me." Which nursing diagnosis applies?

A) Hopelessness
B) Spiritual distress
C) Spiritual dysfunction
D) Disturbed thought processes

Question 12

A nurse assessing a new patient asks,"What is meant by the old saying,'You can't judge a book by looking at the cover'?" Which aspect of cognition is the nurse assessing?

A) Memory
B) Orientation
C) Attention
D) Abstraction

Question 13

A newly admitted patient is severely depressed,lost 20 pounds over the past month,and expresses hopelessness for the future.Select the priority nursing diagnosis.

A) Imbalanced nutrition: less than body requirements
B) Chronic low self-esteem
C) Risk for suicide
D) Powerlessness

Question 14

An adolescent asks the nurse,"Why should I tell you anything? You'll just tell my parents whatever you find out." Select the nurse's best reply.

A) "That isn't true.What you tell us is private and held in strictest confidence.Your parents have no right to know."
B) "Anything you say about feelings is private,but some things like suicidal thinking must be reported to the treatment team."
C) "Yes,your parents may find out what you say,but it is important that they know about your problems."
D) "It sounds as though you are not really ready to work on your problems and make changes."

Question 15

Which statement made by a patient should serve as the priority focus for the plan of care?

A) "I can always trust my family."
B) "It seems like I always have bad luck."
C) "You never know who will turn against you."
D) "I've been hearing the voices of my dead parents."

Question 16

A nurse assesses an elderly patient brought to the emergency department by a grandchild who found the patient wandering in the front yard saying,"I can't find my way home." The patient is confused and unable to answer questions.Select the nurse's next action.

A) Document the confusion.Obtain other assessment data from the grandchild.
B) Record the patient's answers to questions on the hospital assessment form.
C) Ask a more experienced nurse to perform the assessment interview.
D) Call for a mental health advocate to support the patient's rights.

Question 17

At what point in an assessment interview could a nurse logically ask,"How does your faith help you in stressful situations?" During the assessment of:

A) childhood growth and development.
B) substance use and abuse.
C) educational background.
D) coping strategies.

Question 18

A severely depressed patient lost 20 pounds over the past month,has chronic low self-esteem,and the intent and a plan for suicide.The patient has taken an antidepressant medication for 1 week.The nurse adds this outcome to the plan of care: Patient will refrain from gestures and attempts to harm self.Which nursing intervention is most directly related to this outcome?

A) Implement suicide precautions
B) Offer high-calorie snacks and fluids frequently
C) Assist the patient to identify three personal strengths
D) Observe patient for therapeutic effects of antidepressant medication

Question 19

Select the best outcome for a patient with this nursing diagnosis: Impaired social interaction related to sociocultural dissonance as evidenced by stating,"Although I'd like to,I don't join in because I don't speak the language very well." Within 1 week,the patient will:

A) demonstrate improved social skills.
B) express a desire to interact with others.
C) become more independent in decision making.
D) select and participate in one group activity per day.

Question 20

During an initial assessment,a patient becomes anxious and evasive when the nurse asks,"Have you ever heard voices when no one else was around?" The patient asks,"Why do you need to know that?" Select the nurse's best response.

A) "Please be honest about these experiences," and repeat the question.
B) "Sometimes questions seem very personal,but we have our reasons for asking."
C) "What purpose do you think we might have in asking whether you hear voices?"
D) "I can see this subject makes you uncomfortable.We can discuss it another time."

Question 21

After a nurse assesses a new patient with a psychiatric disorder,nursing diagnoses are formulated.Information conveyed by the nursing diagnoses includes: (More than one answer is correct. )

A) medical judgments about the disorder.
B) goals and outcomes for the plan of care.
C) unmet patient needs present at the moment.
D) supporting data that validate the diagnoses.
E) probable causes that will be targets for nursing interventions.

Question 22

The scope of practice for an advanced practice psychiatric nurse adds which interventions beyond the basic level? You may select more than one answer.

A) Perform mental health assessment interviews
B) Prescribe psychotropic medication
C) Establish therapeutic relationships
D) Consultation with other clinicians
E) Psychotherapy

Question 23

A patient has these nursing diagnoses.Prioritize them,beginning with the highest priority.

A) Social isolation
B) Spiritual distress
C) Self-care deficit syndrome

Question 24

A patient is very suspicious and states,"The FBI has me under surveillance." Which strategies should the nurse to use when gathering initial assessment data about this patient? More than one answer is correct.

A) Say to the patient,"Tell me about the problem as you see it."
B) Tell the patient medication will help this type of thinking.
C) Seek information about when the problem began.
D) Tell the patient,"Your ideas are not realistic."
E) Reassure the patient,"You are safe here."

Question 25

A nurse assessing a patient with a substance use disorder decides to use a standardized rating scale.Which scale(s)are appropriate? More than one answer is correct.

A) Addiction Severity Index (ASI)
B) Brief Drug Abuse Screen Test (B-DAST)
C) Abnormal Involuntary Movement Scale (AIMS)
D) Cognitive Capacity Screening Examination (CCSE)
E) Recovery Attitude and Treatment Evaluator (RAATE)

Question 26

When a new patient is hospitalized,a nurse takes the patient on a tour,explains rules of the unit,and explains the daily schedule.The nurse has fulfilled which aspect of care coordination?

A) Counseling
B) Health teaching
C) Milieu management
D) Integrative therapy

Question 27

After formulating the nursing diagnoses for a new patient,what is the nurse's next action?

A) Implement the nursing plan of care.
B) Complete the spiritual assessment.
C) Determine the goals and outcome criteria.
D) Design interventions to include in the plan of care.

Question 28

A patient tells the nurse,"I feel very restless,and my muscles are stiff." Correctly sequence these actions,according to nursing process.

A) Administer medication to relieve the symptoms.
B) Confer with the health care provider about the findings.
C) Determine the measure of relief the patient experienced.
D) Collect additional information about the patient's complaints.
E) Decide the patient is experiencing side effects of antipsychotic medication.

Question 29

A patient participated reluctantly,answered questions with minimal responses and rarely made eye contact during a nursing assessment.What data should be included when documenting the assessment? You may select more than one answer.

A) The patient's verbal responses.
B) The observation that the patient was uncooperative.
C) A description of the patient's behavior during the interview.
D) Observations related to the patient's subjective responses.
E) Analysis of why the patient did not respond openly during the interview.