Chapter 9. The Nursing Process in Psychiatric/Mental Health Nursing
A client is diagnosed with generalized anxiety disorder. In order to maximize the learning process prior to discharge teaching, which assessment should be performed by the nurse? A. Assessing the client's level of anxiety B. Assessing and documenting the client's vital signs C. Assessing suicide risk D. Assessing availability of support systems
ANS: A Anxiety at a moderate or higher level will interfere with the learning process. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity
An adolescent client has problems expressing anger appropriately. Which nursing statement would encourage the client to set realistic goals? A. "What do you think needs to change about how you express anger?" B. "How did you feel after attending the anger management session?" C. "On a scale of 1 to 10, please rate your current level of anger." D. "What bothers you about the actions of others when you get angry?"
ANS: A In the planning phase of the nursing process, the nurse works with the client to identify expected outcomes for a plan individualized to the client or to the situation. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Psychosocial Integrity
The nurse should recognize which acronym as representing problem-oriented charting? A. SOAPIE B. SOLER C. DAR D. PQRST
ANS: A The acronym SOAPIE represents problem-oriented charting, which reflects the subjective, objective, assessment, plan, implementation, and evaluation format. This type of charting identifies nursing diagnoses (client problems) on a written plan of care with appropriate nursing interventions described for each. KEY: Cognitive Level: Comprehension | Integrated Processes: Communication and Documentation | Client Need: Safe and Effective Care Environment
The following outcome was developed for a client: "Client will list five personal strengths by the end of day 1." 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 processes 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
ANS: A The nurse should determine that altered self-esteem and self-deprecating statements would generate the outcome to list personal strengths by the end of day 1. Self-care deficit, disturbed body image, and risk for disturbed self-concept would generate specific outcomes in accordance with specific needs and goals. The self-care deficit and risk for disturbed self-concept nursing diagnoses are incorrectly written. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis | Client Need: Psychosocial Integrity
The following North American Nursing Diagnosis Association (NANDA) 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? A. The client is receiving electroconvulsive therapy (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.
ANS: A The nurse should identify that a client receiving ECT and who is diagnosed with Parkinsonism is at risk for injury due to confusion and potential for falls. History of suicide and hopelessness would lead to the development of nursing diagnosis of risk for suicide. Disorganized thoughts and delusional thinking would lead to the development of a nursing diagnosis of altered thought processes. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis | Client Need: Physiological Integrity
Which of the following nursing interventions fall within the standards of psychiatric-mental health clinical nursing practice for a nurse generalist? Select all that apply. A. Assist clients to perform activities of daily living. B. Act as a consultant with other clinicians to provide services for clients and effect system change C. Encourage clients to discuss triggers for relapse D. Use prescriptive authority in accordance with state and federal laws E. Educate families about signs and symptoms of alcohol dependence and withdrawal
ANS: A, C, E Assisting clients to perform daily living activities, encouraging clients to discuss triggers, and educating families are nursing interventions that fall within the standards of psychiatric clinical nursing practice for a nurse generalist. Psychiatric-mental health advanced practice registered nurses can consult with other clinicians and use prescriptive authority. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment
A client is assigned the nursing diagnosis of impaired social interaction R/T sociocultural differences AEB client stating, "Although I'd like to, I don't join in because I don't speak the language so good." Which correctly written outcome addresses this client's problem? A. The client will collaborate with nursing staff to set specific goals by day 3. B. The client will participate in one group activity of choice by day 2. C. The client will express a desire to interact with others. D. The client will become increasingly independent by discharge.
ANS: B In the planning phase of the nursing process, the nurse works with the client to identify expected outcomes for a plan individualized to the client need or to the situation. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Psychosocial Integrity
During the implementation phase of the nursing process, a nurse is teaching an adult depressed patient with a cochlear implant about medications. Which modification in the teaching plan would be the most appropriate for this client? A. Using repetition B. Speaking directly face-to-face C. Employing the use of sign language D. Providing large-print materials
ANS: B Speaking face-to-face is an appropriate way to teach individuals with alterations in hearing. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment
Within the nurse's scope of practice, which function is exclusive to the advance 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
ANS: B The advanced practice psychiatric nurse is authorized to use psychotherapy to improve mental health. This includes individual, couples, group, and family psychotherapy. It is within the scope of practice of a registered psychiatric mental health nurse generalist to provide education, case management, and milieu therapy. KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment
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.
ANS: B The assessment of clients diagnosed with psychiatric problems should provide a holistic view of the client. A thorough assessment involves collecting and analyzing data from the client, significant others, and health-care providers that may include the following dimensions: physical, psychological, sociocultural, spiritual, cognitive, developmental, economic, lifestyle, and functional abilities. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Safe and Effective Care Environment
Which nursing diagnosis should a nurse identify as being correctly formulated? A. Schizophrenia R/T biochemical alterations AEB altered thought B. Self-care deficit: hygiene R/T altered thought as AEB disheveled appearance C. Depressed mood R/T multiple life stressors D. Developmental disability R/T early-onset schizophrenia AEB hallucinations
ANS: B The nurse should determine that the correctly written diagnosis would be Self-care deficit: hygiene R/T altered thought AEB disheveled appearance. The nursing diagnosis should describe the unhealthy response (inference), the contributing factors, and the data that support the inference. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Analysis | Client Need: Psychosocial Integrity
How should 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
ANS: B The nurse should prioritize nursing diagnoses related to life-threatening potential. Safety is always the nurse's first priority. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis | Client Need: Safe and Effective Care Environment
A client diagnosed with schizophrenia is exhibiting nonverbal behaviors indicating that the client is hearing things that others do not. Which nursing diagnosis accurately reflects this client's problem? A. Altered thought processes B. Altered sensory perception C. Anxiety D. Chronic confusion
ANS: B The nursing diagnosis altered sensory perception accurately reflects the client's symptoms of hearing things that others do not. A nursing diagnosis describes a client's condition and facilitates the prescription of interventions. Delusional thinking, confusion, and disorientation are problems associated with the nursing diagnosis of altered thought processes. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Analysis | Client Need: Psychosocial Integrity
A nursing instructor is teaching students about the purpose of using the nursing process in the care of psychiatric patients. Which of the following statements by the student indicates that learning has occurred? A. The nursing process is a method for interviewing the patient in a systematic way. B. The nursing process is used to assist patients to adapt successfully to stressors within the environment. C. The nursing process is used to provide support for the psychiatric diagnosis. D. The nursing process is used primarily to minimize allegations of negligence.
ANS: B The nursing process is a method for nursing care delivery in which the patient's unhealthy responses are identified and interventions are planned, which are designed to assist the patient to adapt more successfully in their environment. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity
What is the purpose when a nurse gathers client information? A. It enables the nurse to modify client behaviors related to personality disorders. B. It enables the nurse to make sound clinical judgments and plan appropriate client care. C. It enables the nurse to prescribe the appropriate medications. D. It enables the nurse to assign the appropriate Axis I diagnosis.
ANS: B The purpose of gathering client information is to enable the nurse to make sound clinical nursing judgments and plan appropriate care. The nurse should complete a thorough assessment of the client, including information collected from the client, significant others, and health-care providers (consistent with HIPAA laws and the client's right to confidentiality). KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Safe and Effective Care Environment
After a comprehensive assessment, correctly written nursing diagnoses developed for psychiatric clients may include which of the following components? Select all that apply. A. Medical judgments related to the psychiatric disorder B. Unmet client needs present at the moment C. Supporting data that validate the diagnosis D. Outcomes that will be targets for nursing interventions E. Statements of client problems of a functional nature
ANS: B, C, E A nursing diagnosis is a statement of a client's functional problem. An actual nursing diagnosis must include related to (R/T) and as evidenced by (AEB) statements. A "risk for" diagnosis does not contain AEB because there is only a potential for the problem; it does not yet exist. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Analysis | Client Need: Safe and Effective Care Environment
A client diagnosed with major depressive disorder states, "Why should I keep trying to get a job? I mess up everything I do." Which correctly written nursing diagnosis best reflects the content and mood themes in this client's statement? A. Hopelessness R/T poor job performance B. Risk for impaired adjustment R/T inadequate social skills AEB isolation C. Altered role performance R/T the fear of failure AEB not seeking employment D. Chronic low self-esteem R/T major depressive disorder AEB self-hatred
ANS: C An actual nursing diagnosis must include related to (R/T) and as evidenced by (AEB) statements. A "risk for" diagnosis does not contain AEB because there is only a potential for the problem; it doesn't yet exist. The client's statement indicates that role performance is altered because fear of failure prevents seeking employment. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis | Client Need: Psychosocial Integrity
The nurse interviewed a client who was uncooperative, answered questions with minimal responses, and rarely made eye contact. Which is the most complete documentation of baseline data obtained during the interview? A. "Appears uncooperative. Exhibits characteristics of depression." B. "Maintains poor eye contact throughout interview process. Unable to answer interview questions due to depression." C. "States 'I don't need to be here' when discussing admission status. Maintains minimal eye contact and offers little data related to triggers for admission." D. "Unwilling to respond openly during interview."
ANS: C Documentation occurs in the implementation phase of the nursing process. All charting entries to the client's legal record should be objective and based on assessed data. Implications and generalizations should be avoided. KEY: Cognitive Level: Application | Integrated Processes: Communication and Documentation | Client Need: Safe and Effective Care Environment
The following clients are seen in the emergency department. The psychiatric unit has one remaining bed. The triage nurse should expect which client to be admitted? A. The client who is experiencing tremors and has a need for medication adjustment B. The client who is experiencing anxiety and a sad mood after separation from spouse C. The client who is a single parent and hears voices stating, "Kill your infant son." D. The client who argued with her boyfriend and inflicted a superficial cut on her arm
ANS: C In the assessment phase of the nursing process, the nurse collects comprehensive health data that are pertinent to the client's health or situation. These data are prioritized to meet client needs, with an emphasis on safety. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Safe and Effective Care Environment
A student nurse asks an instructor which resource is best to use when developing nursing outcomes for clients. Which reply by the instructor most accurately answers the student's question? A. "Use the Nursing Interventions Classification (NIC), as a reference for nursing outcomes." B. "Use the NANDA resource to identify appropriate outcomes." C. "Use the Nursing Outcomes Classification (NOC), as a reference for nursing outcomes." D. "Copy your standard outcomes from a nursing care plan textbook."
ANS: C NOC is a comprehensive, standardized classification of client outcomes developed to evaluate the effects of nursing interventions. NANDA is a resource for identifying approved nursing diagnoses. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Safe and Effective Care Environment
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. MMSE D. CAPS scale
ANS: C The MMSE, or mini mental status exam, would be the appropriate tool to use to assess the mental acuity of a client prior to and immediately following ECT. The CIWA scale, or clinical institute withdrawal assessment scale, would be used to assess withdrawal from substances such as alcohol. The CAPS refers to the clinician-administered PTSD scale and would be used to assess signs and symptoms of PTSD. The GGT test is used to assess gamma-glutamyl transferase levels, which may be an indication of alcoholism. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Safe and Effective Care Environment
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
ANS: C The milieu manager implements care by scheduling client activities, interacting with clients, and maintaining a safe therapeutic environment. Health teaching involves promoting health and a safe environment. Case management is utilized to organize client care so that outcomes are achieved. Psychotherapy involves conducting individual, couples, group, and family counseling. KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment
Which data-gathering technique is employed during the assessment phase of the nursing process? A. Asking the client to rate mood after administering an antidepressant B. Asking the client to verbalize understanding of previously explained unit rules C. Asking the client to describe any thoughts of self-harm D. Asking the client if the group on assertiveness skills was helpful
ANS: C The nurse should ask the client to describe any thoughts of self-harm during the assessment phase of the nursing process. Assessment involves collecting and analyzing data about the client that may include the following dimensions: physical, psychological, sociocultural, spiritual, cognitive, developmental, economic, lifestyle, and functional abilities. The other three options are employed during the evaluation phase of the nursing process. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Safe and Effective Care Environment
ANS: C The MMSE, or mini mental status exam, would be the appropriate tool to use to assess the mental acuity of a client prior to and immediately following ECT. The CIWA scale, or clinical institute withdrawal assessment scale, would be used to assess withdrawal from substances such as alcohol. The CAPS refers to the clinician-administered PTSD scale and would be used to assess signs and symptoms of PTSD. The GGT test is used to assess gamma-glutamyl transferase levels, which may be an indication of alcoholism. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Safe and Effective Care Environment
ANS: C The nurse should ask the client to identify name, date, residential address, and situation to assess the client's orientation. Assessment of the client's orientation to reality is part of a mental status evaluation. KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity
Which statement regarding nursing interventions should a nurse identify as accurate? A. Nursing interventions are independent from the treatment team's goals. B. Nursing interventions are directed solely by written physician orders. C. Nursing interventions occur independently but in concert with overall treatment team goals. D. Nursing interventions are standardized by policies and procedures.
ANS: C The nurse should understand that nursing interventions occur independently but in concert with overall treatment goals. Nursing interventions should be developed and implemented in collaboration with other health-care professionals involved in the client's care. KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment
A client has a nursing diagnosis of Insomnia R/T paranoid thinking AEB midnight awakenings, difficulty falling asleep, and daytime napping. Which is a correctly written and appropriate outcome for this client's problem? 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 7 uninterrupted hours by day four of hospitalization. D. The client's sleep habits will improve during hospitalization.
ANS: C The outcome "The client will sleep 7 uninterrupted hours by day four of hospitalization" is accurately written and an appropriate outcome to address the client problem of insomnia. Outcomes should be measurable, realistic, client-focused goals that include a time frame. Appropriate nursing interventions are guided by client outcomes. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Planning | Client Need: Psychosocial Integrity
Which of the following are characteristics of accurately developed client outcomes? Select all that apply. A. Client outcomes are formulated by nurses independent from other team members. 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.
ANS: C, D The nurse should identify that client outcomes should be specific, measurable, and realistically based on client capability. Outcomes should be derived from the diagnosis and should include a time estimate for attainment. Outcomes are most effective when formulated cooperatively by the interdisciplinary team members, client, and significant others. KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Planning | Client Need: Safe and Effective Care Environment
A nurse charts "Verbalizes understanding of the side effects of Prozac." This is an example of which category of focused charting? A. Data B. Problem C. Action D. Response
ANS: D "Verbalizes understanding of the side effects of Prozac" is an example of the response category of focused charting. The response is a description of the client's reaction to any part of medical or nursing care. KEY: Cognitive Level: Application | Integrated Processes: Communication and Documentation | Client Need: Safe and Effective Care Environment
A client who has slept 6 hours the previous night reports this to the assigned psychiatric nurse. What should be the initial nursing action to address this situation? A. Provide warm milk and a backrub. B. Give a sleep medication. C. Hold a relaxation group before bedtime. D. Review the client's normal sleep pattern.
ANS: D In the assessment phase of the nursing process, the nurse collects comprehensive health data that are pertinent to the client's health or situation. In this situation the nurse must initially determine the client's normal sleep patterns in order to evaluate if a true problem exists. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client Need: Safe and Effective Care Environment
An instructor overhears a student say, "That family seems to disagree more than agree. The family seems to be dysfunctional." To further assess the family's situation, which would be an appropriate instructor reply? A. "Families who disagree can be a challenge to the treatment team." B. "You seem very critical of the family. Do you believe that you are unable to help them?" C. "Let's bring the family in for an educational session to improve their communication." D. "What appears to trigger family disagreements?"
ANS: D In the assessment phase of the nursing process, the nurse collects comprehensive health data that are pertinent to the client's health or situation. In this situation, prior to intervening with this family, the nurse needs further information about the cause of family conflicts. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Safe and Effective Care Environment
During an intake interview, which question would assist the nurse in gathering data about the client's judgment? A. "What brought you to the hospital? Do you know what day and season it is now?" B. "On a scale of 1 to 10, how would you rate your stress level?" C. "What does the phrase 'a rolling stone gathers no moss' mean to you?" D. "If you found a stamped, addressed envelope in the street, what would you do?"
ANS: D In the assessment phase of the nursing process, the nurse collects comprehensive health data that are pertinent to the client's health or situation. The nurse presents a situation that requires the client to make a judgment call and can assess appropriate judgment on the basis of the client's action choice. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity
Which nursing response would be appropriately used in the evaluation phase of the nursing process? A. "If I were in your situation, I would not repeat a behavior that has caused problems." B. "What do you think needs changing, and what do you want to do differently?" C. "What exactly will it take to carry out your plan, and what else do you need to do?" D. "It sounds like you're saying this new approach is working for you."
ANS: D In the evaluation phase of the nursing process, the nurse and the client evaluate progress toward attainment of the expected outcomes. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity
Which expected client outcome should a nurse identify as being correctly formulated? A. Client will feel happier by discharge. B. Client will demonstrate two relaxation techniques. C. Client will verbalize triggers to anger by end of session. D. Client will initiate interaction with one peer during free time within 2 days.
ANS: D The statement "Client will initiate interaction with one peer during free time within 2 days" is an example of a correctly formulated expected outcome. Outcomes should be measurable, realistic, client-focused goals that include a time frame. Appropriate nursing interventions are guided by client outcomes. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Psychosocial Integrity
