Deck 6: The Nursing Process in Psychiatricmental Health Nursing

Question 1

Which describes the primary purpose of a registered nurse gathering client information?

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

Answer 1

It enables the nurse to make sound clinical judgments and plan appropriate care.

Question 2

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?

A) Altered self-esteem R/T years of emotional abuse AEB self-deprecating statements
B) Self-care deficit R/T altered thought process
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 2

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

Question 3

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

Answer 3

nursing diagnosis

Question 4

How would 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 5

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 6

______ is a diagrammatic teaching and learning strategy that allows students and faculty to visualize interrelationships between medical diagnoses, nursing diagnoses, assessment data, and treatments.

Question 7

The following NANDA-I 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

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 9

Which function is exclusive to the advanced practice psychiatric nurse?

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 10

Which characteristics of accurately developed client outcomes would a nurse identify? (Select all that apply.)

A) Client outcomes are specifically formulated by nurses.
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 11

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) BMSE
D) CAPS scale

Question 12

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

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

Question 13

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

A) Nursing interventions are independent from the treatment team's goals.
B) Nursing interventions are solely directed by written physician orders.
C) Nursing interventions are comprehensive and reflect current clinical nursing practice
D) Nursing interventions are standardized by policies and procedures.

Question 14

Which 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 15

Which response by the instructor most accurately answers the student's question regarding how to best develop nursing outcomes for clients?

A) "You can use NIC, a standardized reference for nursing outcomes."
B) "Look at your client's problems and set a realistic, achievable goal."
C) "With client collaboration, outcomes would be based on client problems."
D) "Copy your standard outcomes from a nursing care plan textbook."

Question 16

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?

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 seven uninterrupted hours by day four of hospitalization.
D) The client's sleep habits will improve during hospitalization.