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

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?

A) Holistic
B) Spiritual
C) Biological
D) Psychosocial

Answer 1

Holistic

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?

A) It begins at the first face-to-face meeting with the patient and continues until the evaluation phase.
B) It begins at the first face-to-face meeting with the patient and continues until the patient leaves the setting.
C) It may begin prior to the first face-to-face meeting with the patient, and it continues until the diagnosis phase.
D) It may begin prior to the first face-to-face meeting with the patient, and it continues until the patient leaves the setting.

Answer 2

It may begin prior to the first face-to-face meeting with the patient, and it continues until the patient leaves the setting.

Question 3

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

A) The patient's disease or condition
B) The severity of the patient's disease or condition
C) The patient's adaptation to the disease or condition
D) How the patient's disease or condition will be treated
E) How the patient's disease or condition affects the patient's life

Answer 3

The patient's adaptation to the disease or condition
How the patient's disease or condition affects the patient's life

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.

A) "How old are you?"
B) "Are you experiencing any pain today?"
C) "Can you tell me what year it is?"
D) "Are you having any thoughts of suicide?"
E) "Do you have a history of cardiac disease?"

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.

A) Renegotiating patient needs to be addressed
B) Identifying new, different, or additional goals and outcomes
C) Redefining the roles of the patient and nurse in achieving outcomes
D) Choosing appropriate interventions according the patient assessment
E) Determining what progress has been made relevant to the plan of care

Question 6

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

A) Planning
B) Diagnosis
C) Evaluation
D) Assessment
E) Communication

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?

A) Determine mutual goals of care.
B) Identify patient information and history.
C) Establish and document the nursing diagnosis.
D) Establish a therapeutic nurse-patient relationship.

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.

A) Naming the problem
B) Etiology of the problem
C) Identifying the disease or disorder
D) Providing appropriate intervention according to the identified problem
E) Providing data regarding the problem or the signs and symptoms present

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?

A) Determine the patient's state of mind.
B) Suspend expectations about the patient.
C) Determine how the patient will present.
D) Suspend reflection about the patient's condition.

Question 10

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

A) The nursing diagnosis is more general.
B) The nursing diagnosis is more effective.
C) The nursing diagnosis is more accurate.
D) The nursing diagnosis is more specific.

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.

A) Speech
B) Attitude
C) Emotional status
D) Substance use
E) Cognitive functioning

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.

A) It can be used to evaluate the success of nursing interventions.
B) It can be used as both an assessment tool and an intervention.
C) It can be used to identify significant events across the life span.
D) It involves the patient in providing historical information.
E) It helps the patient gain perspective on problems that have not been resolved.

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.

A) Memory
B) Judgment
C) Emotional status
D) Thought processes
E) State of consciousness

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?

A) Asking the patient what year it is.
B) Asking the patient the name of the president.
C) Asking the patient to interpret a known proverb.
D) Asking the patient to spell the word 'world' both forward and backward.

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?

A) Cultural
B) Biological
C) Sociological
D) Psychological

Question 16

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

A) Steps to resolve the problem
B) The cause of the problem
C) The focal pattern, problem, or behavior that is observed
D) Data that indicate or support the problem statement

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?

A) Social
B) Spiritual
C) Biological
D) Psychological

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?

A) Determine if the voices are fantasy hallucinations.
B) Determine if the voices are command hallucinations.
C) Determine if the patient has a disturbance in orientation.
D) Determine if the patient has a disturbance in thought process.

Question 19

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

A) Reviewing the patient's health care chart
B) Agreeing with the patient on stated treatment goals
C) Providing the patient with information on the ordered medication
D) Re-addressing patient interventions after a change in the patient's status

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?

A) "Please tell me the name of our president."
B) "Please spell the word 'world' forward and backward."
C) "Please tell me your name, the date, and where you are right now."
D) "Please tell me what the meaning is of the statement, 'A picture paints a thousand words.'"

Question 21

The nurse is caring for a patient with a major depressive disorder who tells the nurse that she is unable to leave her house and stays in bed most days of the week. When planning care for this patient, what priority nursing diagnosis will the nurse formulate?

A) Chronic fatigue due to depression, as evidenced by the inability to get out of bed
B) Social isolation due to depression, as evidenced by the inability to leave the house
C) Chronic fatigue caused by depression, manifested by the inability to get out of bed
D) Social isolation caused by depression, manifested by the inability to leave the house

Question 22

The nurse is caring for a patient with bipolar disorder who has been awake for 72 hours and has eaten only small amounts of food. The patient's speech is pressured and unorganized. When planning care for this patient, what priority nursing diagnosis will the nurse formulate?

A) Alteration of sleeping pattern due to acute mania, as evidenced by decreased sleep.
B) Alteration of sleeping pattern caused by acute mania, manifested by decreased sleep.
C) Risk for injury caused by acute mania, manifested by altered nutrition, decreased sleep, and pressured speech.
D) Risk for injury due to acute mania, as evidenced by altered nutrition, decreased sleep, and pressured speech.

Question 23

The nurse who is caring for a patient with mental illness has performed the nursing assessment and formulated the nursing diagnosis. What is the purpose of the next phase of the nursing process?

A) Evaluating stated outcomes
B) Establishing measurable goals
C) Implementing measurable interventions
D) Assessing mental status compared to nursing assessment

Question 24

The nurse is evaluating the goals and outcomes of patient who is being discharged with a diagnosis of major depressive disorder. Why is the met versus not-met framework of evaluating goals and outcomes not the most effective method, though it is the most widely used method?

A) It is less effective at defining the specific goal or outcome.
B) It less effective at identifying a specific goal or outcome.
C) It is less effective at documenting the results of the goal or outcome.
D) It is less effective at specifying progress toward meeting the goal or outcome.

Question 25

The nurse is caring for a patient diagnosed with anxiety. Which is the priority for assessment for a patient with anxiety?

A) Patient safety
B) Signs of mania
C) Objective symptoms
D) Subjective symptoms

Question 26

The nurse is planning care for a patient who is in the recovery phase of illness. The nurse knows which is a focus of care for a patient in the recovery phase of illness?

A) Patient safety
B) Stability of symptoms
C) Coping skills and problem solving
D) Impact of symptoms on quality of living

Question 27

When reviewing the plan of care for a patient with mental illness, the nurse notes that the patient is not meeting one of the established goals. What is the nurse's best action?

A) Collaborate with the patient to reassess the plan of care.
B) Collaborate with the health care provider to reassess the plan of care.
C) Change the plan of care according to the patient's most recent assessment.
D) Change the plan of care according to the newly defined nursing diagnosis.

Question 28

The nurse is caring for a patient with acute mania and is planning appropriate goals and outcomes for the patient's care. Which goal meets all the requirements for a properly-stated patient goal?

A) The patient will sleep 6 hours a night within 3 days.
B) The nurse will assess the patient for acute mania daily.
C) The nurse will provide the patient at least 3 meals per day.
D) The patient will have a normal mood pattern by October 15.

Question 29

The nurse is planning care for a patient with mental illness. What is true regarding patient goals?

A) They should be clear and general.
B) They should be general and open-ended.
C) They should be concrete and measurable.
D) They should be universal and standard.

Question 30

The nurse is caring for a patient with mental illness who tells the nurse, "I can't sleep anymore." What is the nurse's best response?

A) "Is this a daily problem?"
B) "You have trouble sleeping?"
C) "Do you have a sleep routine?"
D) "How much sleep do you get at night?"

Question 31

The nurse is evaluating the goals and outcomes of a patient with mental illness. What is the purpose of a patient-specific outcome?

A) It guides the nurse to the appropriate nursing diagnosis.
B) It guides the nurse to the appropriate nursing interventions.
C) It allows the nurse to define the particular steps made toward improved health.
D) It allows the nurse to perform a focused assessment based on the particular outcome.

Question 32

The nurse is performing a nursing assessment on a patient who is diagnosed with severe mental illness. Which type of intervention best illustrates the nurse's action?

A) Diagnostic
B) Evaluative
C) Therapeutic
D) Educational

Question 33

The nurse is planning care for a newly admitted patient with mental illness. According to the nursing process, what is the nurse's next action, after formulating the patient's nursing diagnosis?

A) Evaluate goals for their appropriateness.
B) Identify problems and their priority in care.
C) Assess the patient according to the stated diagnosis.
D) Implement interventions according to the stated diagnosis.

Question 34

The nurse is caring for a patient with schizophrenia who is experiencing auditory hallucinations. The patient tells the nurse, "The voices in my head are telling me to do things that I don't want to do." When planning care for this patient, what is the priority nursing diagnosis that the nurse will formulate?

A) Risk for violence caused by schizophrenia, manifested by command hallucinations.
B) Risk for violence due to auditory hallucinations, as evidenced by command hallucinations.
C) Disturbed thought processes due to schizophrenia, as evidenced by command hallucinations.
D) Disturbed thought processes due to auditory hallucinations, manifested by command hallucinations.

Question 35

The nurse is caring for a patient with schizophrenia who is recovering from open abdominal surgery. The nurse observes the patient grimacing and guarding his abdomen. From the information provided, what priority nursing diagnosis will the nurse formulate for this patient?

A) Disturbed thought processes due to surgery, evidenced by tachycardia and tachypnea.
B) Acute pain due to surgery, evidenced by facial grimacing, tachycardia, and tachypnea.
C) Acute pain caused by surgery, manifested by facial grimacing, tachycardia, and tachypnea.
D) Disturbed thought processes caused by schizophrenia, manifested by tachycardia and tachypnea.

Question 36

The nurse is planning care for a patient with severe mental illness who tells the nurse, "I am sad all the time and I don't have any motivation to keep going." Which nursing intervention takes priority?

A) Instill hope.
B) Instill empathy.
C) Assess the patient for suicidal ideation.
D) Assess the patient for disturbed sleep patterns.