Chapter 7: The Nursing Process in Psychiatric/Mental Health Nursing. With Answers Explained

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Multiple Choice Identify the choice that best completes the statement or answers the question. ____ 1. Which statement is most accurate regarding the assessment of clients diagnosed with psychiatr... ic problems? 1. Medical history is of little significance and can be eliminated from the nursing assessment. 2. Assessment provides a holistic view of the client, including biopsychosocial aspects. 3. Comprehensive assessments can be performed only by advanced practice nurses. 4. Psychosocial evaluations are gained by subjective reports rather than objective observations. ____ 2. Which statement regarding nursing interventions should a nurse identify as accurate? 1. Nursing interventions are independent from the treatment team’s goals. 2. Nursing interventions are solely directed by written physician orders. 3. Nursing interventions occur independently but in concert with overall treatment team goals. 4. Nursing interventions are standardized by policies and procedures. ____ 3. Within the nurse’s scope of practice, which function is exclusive to the advanced practice psychiatric nurse? 1. Teaching about the side effects of neuroleptic medications 2. Using psychotherapy to improve mental health status 3. Using milieu therapy to structure a therapeutic environment 4. Providing case management to coordinate continuity of health services ____ 4. The nurse should recognize which acronym as representing problem-oriented charting? 1. SOAPIE 2. APIE 3. DAR 4. PQRST ____ 5. Which tool would be appropriate for a nurse to use when assessing mental acuity prior to and immediately following electroconvulsive therapy (ECT)? 1. CIWA scale 2. GGT 3. MMSE 4. CAPS scale ____ 6. What is being assessed when a nurse asks a client to identify name, date, residential address, and situation? 1. Mood 2. Perception 3. Orientation 4. Affect ____ 7. What is the purpose of a nurse gathering client information? 1. It enables the nurse to modify behaviors related to personality disorders. 2. It enables the nurse to make sound clinical judgments and plan appropriate care. 3. It enables the nurse to prescribe the appropriate medications. 4. It enables the nurse to assign the appropriate Axis I diagnosis. ____ 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? 1. Health teacher 2. Case manager 3. Milieu manager 4. Psychotherapist ____ 9. 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? 1. Altered self-esteem R/T years of emotional abuse AEB self-deprecating statements 2. Self-care deficit R/T altered thought process 3. Disturbed body image R/T major depressive disorder AEB mood rating of 2/10 4. Risk for disturbed self-concept R/T hopelessness AEB suicide attempt ____ 10. How should a nurse prioritize nursing diagnoses? 1. By the established goal of care 2. By the life-threatening potential 3. By the physician’s priority of care 4. By the client’s preference ____ 11. 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? 1. The client will avoid daytime napping and attend all groups. 2. The client will exercise, as needed, before bedtime. 3. The client will sleep seven uninterrupted hours by day four of hospitalization. 4. The client’s sleep habits will improve during hospitalization. ____ 12. The following NANDA-I nursing diagnostic stem was developed for a client on an inpatient unit: Risk for injury. What assessment data most likely led to the development of this problem statement? 1. The client is receiving ECT and is diagnosed with Parkinsonism. 2. The client has a history of four suicide attempts in adolescence. 3. The client expresses hopelessness and helplessness and isolates self. 4. The client has disorganized thought processes and delusional thinking. ____ 13. A student nurse asks an instructor how best to develop nursing outcomes for clients. Which response by the instructor most accurately answers the student’s question? 1. “You can use NIC, a standardized reference for nursing outcomes.” 2. “Look at your client’s problems and set a realistic, achievable goal.” 3. “With client collaboration, outcomes should be based on client problems.” 4. “Copy your standard outcomes from a nursing care plan textbook.” ____ 14. A client diagnosed with schizophrenia is exhibiting nonverbal behaviors indicating that the client is hearing things that others do not. Which nursing diagnosis, which was recently removed from the NANDA-I list, still accurately reflects this client’s problem? 1. Disturbed thought processes 2. Disturbed sensory perception 3. Anxiety 4. Chronic confusion Multiple Response Identify one or more choices that best complete the statement or answer the question. ____ 15. Which of the following characteristics of accurately developed client outcomes should a nurse identify? (Select all that apply.) 1. Client outcomes are specifically formulated by nurses. 2. Client outcomes are not restricted by time frames. 3. Client outcomes are specific and measurable. 4. Client outcomes are realistically based on client capability. 5. Client outcomes are formally approved by the psychiatrist. Other 16. Number the following nursing interventions as they would proceed through the steps of the nursing process. ________ Determine if an antianxiety medication is decreasing a client’s stress. ________ Measure a client’s vital signs and review past history. ________ Encourage deep breathing and teach relaxation techniques. ________ Aim, with client collaboration, for a seven-hour night’s sleep. ________ Recognize and document the client’s problem. Completion Complete each statement. 17. A _________________ __________________ provides the basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability. [Show More]

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