Deck 6: The Nursing Process and Standards of Care for Psychiatric Mental Health Nursing

Question 1

At what point in an assessment interview would a nurse ask, "How does your faith help you in stressful situations?"

A) During the assessment of childhood growth and development
B) During the assessment of substance use and abuse
C) During the assessment of educational background
D) During the assessment of coping strategies

Answer 1

During the assessment of coping strategies

Question 2

Who is the best person to provide information about a 4-year-old's behaviour, attitude, and performance?

A) The child
B) The parent(s)
C) The family doctor
D) The psychologist

Answer 2

The parent(s)

Question 3

The desired outcome for a patient experiencing insomnia is, "Patient will sleep for a minimum of 5 hours nightly within 7 days." At the end of 7 days, review of sleep data shows the patient sleeps an average of 4 hours nightly and takes a 2-hour afternoon nap. The nurse will document the outcome as which of the following?

A) Consistently met
B) Often met
C) Sometimes met
D) Unmet

Answer 3

Unmet

Question 4

Nursing behaviours associated with the implementation phase of nursing process are concerned with which of the following?

A) Participating in mutual identification of patient outcomes
B) Gathering accurate and sufficient patient-centred data
C) Comparing patient responses and expected outcomes
D) Carrying out interventions and coordinating care

Question 5

A patient diagnosed with major depression has lost 9 kilograms in one month, has chronic low self-esteem, and a plan for suicide. The patient has taken an antidepressant medication for 1 week. Which nursing intervention has the highest priority?

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 6

A patient states, "I'm not worth anything. I have negative thoughts about myself. I feel anxious and shaky all the time. Sometimes I feel so sad that I want to go to sleep and never wake up." Which nursing intervention should have the highest priority?

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

Question 7

Which statement made by a patient during an initial assessment interview 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 hear evil voices that tell me to do bad things."

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 do which of the following?

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 newly admitted patient diagnosed with major depression has gained 10 kilograms over a few months and has suicidal ideation. The patient has taken an antidepressant medication for 1 week without remission of symptoms. Select the priority nursing diagnosis.

A) Imbalanced nutrition; more than body requirements
B) Chronic low self-esteem
C) Risk for suicide
D) Hopelessness

Question 10

When a new patient is hospitalized, a nurse takes the patient on a tour, explains rules of the unit, and discusses the daily schedule. The nurse is engaged in which of the following?

A) Counselling
B) Health teaching
C) Milieu management
D) Psychobiological intervention

Question 11

An adolescent asks a nurse conducting an assessment interview, "Why should I tell you anything? You'll just tell my parents whatever you find out." Which response by the nurse is appropriate?

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

Question 12

What is the nurse's primary source for data collection?

A) The patient
B) The patients chart
C) The admission history and physical
D) The patient's family or significant other

Question 13

A nurse assesses an older adult patient brought to the emergency department by a family member. The patient was wandering outside saying, "I can't find my way home." The patient is confused and unable to answer questions. Select the nurse's best action.

A) Record the patient's answers to questions on the nursing assessment form.
B) Ask an advanced-practice nurse to perform the assessment interview.
C) Call for a mental health advocate to maintain the patient's rights.
D) Obtain important information from the family member.

Question 14

A patient presents to the emergency department with mixed psychiatric symptoms. The admission nurse suspects the symptoms may be the result of a medical problem. Lab results show elevated BUN (blood urea nitrogen) and creatinine. What is the nurse's next best action?

A) Report the findings to the health care provider.
B) Assess the patient for a history of renal problems.
C) Assess the patient's family history for cardiac problems.
D) Arrange for the patient's hospitalization on the psychiatric unit.

Question 15

Select the best outcome for a patient with the 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."

A) Patient will show improved use of language.
B) Patient will demonstrate improved social skills.
C) Patient will become more independent in decision making.
D) Patient will select and participate in one group activity per day.

Question 16

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

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

Question 17

When a nurse assesses an older adult patient, answers seem vague or unrelated to the questions. The patient also leans forward and frowns, listening intently to the nurse. Which of the following questions would be appropriate for the nurse to ask?

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

Question 18

The desired outcome for a patient experiencing insomnia is, "Patient will sleep for a minimum of 5 hours nightly within 7 days." At the end of 7 days, review of sleep data shows the patient sleeps an average of 4 hours nightly and takes a 2-hour afternoon nap. What is the nurse's next action?

A) Continue the current plan without changes.
B) Remove this nursing diagnosis from the plan of care.
C) Write a new nursing diagnosis that better reflects the problem.
D) Examine interventions for possible revision of the target date.

Question 19

A nurse wants to assess an adult patient's recent memory. Which question would best yield the desired information?

A) "Where did you go to elementary school?"
B) "What did you have for breakfast this morning?"
C) "Can you name the current president of the United States?"
D) "A few minutes ago, I told you my name. Can you remember it?"

Question 20

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

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

Question 21

A patient is very suspicious and states, "The FBI has me under surveillance." Which strategies should a nurse use when gathering initial assessment data about this patient?

A) Tell the patient that medication will help this type of thinking.
B) Ask the patient, "Tell me about the problem as you see it."
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 22

A nurse documents, "Patient is mute despite repeated efforts to elicit speech. Makes no eye contact. Inattentive to staff. Gazes off to the side or looks upward rather than at speaker." Which nursing diagnosis should be considered?

A) Defensive coping
B) Decisional conflict
C) Risk for other-directed violence
D) Impaired verbal communication

Question 23

A nurse prepares to assess a new patient who moved to Canada from Central America three years ago. After introductions, what is the nurse's next comment?

A) "How did you get to Canada?"
B) "Would you like for a family member to help you talk with me?"
C) "An interpreter is available. Would you like for me to make a request for these services?"
D) "Are you comfortable conversing in English, or would you prefer to have a translator present?"

Question 24

A nurse performing an assessment interview for a patient with a substance use disorder decides to use a standardized rating scale. Which scales are appropriate?

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 25

A nurse assessed a patient who reluctantly participated in activities, answered questions with minimal responses, and rarely made eye contact. What information should be included when documenting the assessment?

A) The patient was uncooperative
B) The patient's subjective responses
C) Only data obtained from the patient's verbal responses
D) A description of the patient's behaviour during the interview
E) Analysis of why the patient was unresponsive during the interview

Question 26

The nurse records this entry in a patient's progress notes: Patient escorted to unit by ER nurse at 2130. Patient's clothing was dirty. In interview room, patient sat with hands over face, sobbing softly. Did not acknowledge nurse or reply to questions. After several minutes, abruptly arose, ran to window, and pounded. Shouted repeatedly, "Let me out of here." Verbal intervention unsuccessful. Order for stat dose 2 mg haloperidol PO obtained; medication administered at 2150. By 2215, patient stopped shouting and returned to sit wordlessly in chair. Patient placed on one-to-one observation. How should this documentation be evaluated?

A) Uses unapproved abbreviations
B) Contains subjective material
C) Too brief to be of value
D) Excessively wordy
E) Meets standards

Question 27

Select the most appropriate label to complete this nursing diagnosis: ___________ related to feelings of shyness and poorly developed social skills as evidenced by watching television alone at home every evening.

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

Question 28

What does the nurse assess when completing the final "S" of the HEADSSS Psychosocial Interview Technique?

A) Suicide risk
B) Savagery
C) Sexuality
D) Social support

Question 29

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

A) Designing interventions to include in the plan of care
B) Determining the goals and outcome criteria
C) Implementing the nursing plan of care
D) Completing the spiritual assessment

Question 30

What information is conveyed by nursing diagnoses?

A) Medical judgements about the disorder
B) Unmet patient needs currently present
C) Goals and outcomes for the plan of care
D) Supporting data that validate the diagnoses
E) Probable causes that will be targets for nursing interventions