Mental Health - Chapter 7 - The Nursing Process and Standards of Care

A nurse is caring for a patient with depression. Which tools should the nurse use to assess the severity of depression in the patient? Select all that apply. 1 Beck Inventory 2 Zung Self-Report Inventory 3 Patient Health Questionnaire-9 4 Functional Assessment Screening Tool 5 Scale for Assessment of Negative Symptoms

1 Beck Inventory 2 Zung Self-Report Inventory 3 Patient Health Questionnaire-9 The Beck Inventory, the Zung Self-Report Inventory, and the Patient Health Questionnaire-9 are used as tools to assess depression in patients. The Functional Assessment Screening Tool is used to assess cognitive function in patients. The Scale for Assessment of Negative Symptoms is used to assess schizophrenia in patients.

A nurse is learning about the mental status examination. What does the nurse consider when assessing the appearance of the patient? Select all that apply. 1 Grooming 2 Orientation 3 Level of hygiene 4 Thought process 5 Facial expression

1 Grooming 3 Level of hygiene 5 Facial expression When assessing the appearance of the patient, the nurse should look for grooming, level of hygiene, and facial expressions. Grooming and dressing is observed as a part of examination of appearance. Level of hygiene and personal cleanliness are assessed by examining the appearance. Facial expression can show signs of dullness or nervousness. Orientation cannot be examined by assessment of appearance; it is examined by assessing cognition and mental status of the patient. Thought process is evaluated in disorders of the form of thought in mental assessment.

A nurse is caring for mentally ill patients. Which actions should the nurse perform as a part of the assessment? Select all that apply. 1 Interview 2 History taking 3 Revision of plan 4 Physical examination 5 Problem identification

1 Interview 2 History taking 4 Physical examination Interviews to obtain patients' medical details are a part of assessment. History taking to obtain medical histories of the patients is a part of assessment too. Physical examination, which is performed to obtain physical signs and symptoms of disease, is also a part of assessment. Revision of plan is a part of the evaluation phase. Problem identification helps to find the cause of disease and is a part of diagnosis.

A parent informs the nurse, "My child seems to be in a depressed mood and shows no interest in speaking with others." The laboratory reports of the child showed altered electrolyte levels. What can the nurse interpret from these findings? 1 The child has a chronic renal disorder. 2 The child has a cardiovascular disorder. 3 The child has a chronic endocrine disorder. 4 The child has a chronic gastrointestinal disorder.

1 The child has a chronic renal disorder. Symptoms of physical illnesses have a huge impact on the mental status of patients. Elevated electrolyte levels are an indication of a chronic renal disorder. Symptoms like depression and lack of interest in communicating with others are common findings in patients with such a chronic illness. Elevated electrolyte levels do not indicate cardiovascular, endocrine, or gastrointestinal disorders. Cardiovascular disorders are associated with hypoxia and angina. Endocrine disorders are associated with altered thyroid or insulin levels. Gastrointestinal disorders are associated with elevated liver enzyme levels.

The nurse is interviewing a 17-year-old female patient. She confides that she has been thinking of ways to kill a female peer who is her rival for the volleyball team captain position. She asks you if you can keep it a secret. What is the most appropriate nursing response? 1 "Yes, I will keep it confidential. We have laws to protect patient's confidentiality." 2 "Issues of this kind have to be shared with the treatment team and your parents." 3 "I will have to share this with the treatment team but we will not share it with your parents." 4 "I will keep it a secret, but you and I need to discuss ways to deal with this situation appropriately without committing a crime."

2 "Issues of this kind have to be shared with the treatment team and your parents." Although adolescent patients request confidentiality, issues of sexual abuse, threats of suicide or homicide, or issues that put the patient at risk for harm must be shared with the treatment team and the parents. A threat of this nature must be discussed with the treatment team and the parents. Confidentiality laws do not protect information that would lead to harm to the patient or others. This information would be shared with both the team and the parents.

The nurse prepares to assess an 8-year-old child. Which technique is most appropriate to determine the child's perception of a frightening experience? 1 Use a low-pitched voice tone. 2 Ask the child to draw a picture. 3 Play a video game with the child. 4 Say to the child, "Tell me about your best friend."

2 Ask the child to draw a picture. Age-appropriate communication strategies are important to establish successful communication. Drawing a picture allows the child safe expression of thoughts and emotions the child may have difficulty expressing verbally. Using a low-pitched voice is easier for older adults to hear but not an ideal approach with children. Playing a video game or asking about the child's best friend may establish rapport but does not encourage the child to share a perception of a frightening event.

Documentation in the medical record: "For the first time, the patient contributed verbally in group therapy, shared feelings, and concerns with others, and asked for feedback." To which step of the nursing process does this statement apply? 1 Planning 2 Evaluation 3 Assessment 4 Implementation 5 Nursing diagnosis

2 Evaluation The statement described outcomes associated with group therapy. Progress is evident. These phenomena demonstrate the evaluation step of the nursing process. Evaluation of an individual's response to treatment should be systematic, ongoing, and criteria-based. Supporting data are included to clarify the evaluation. Assessment refers to gathering information. Nursing diagnosis refers to the analysis of the assessment data and formulation of a problem statement. Planning refers to outcome identification and designation of resources. Implementation refers to nursing actions.

When assessing a mentally ill patient, the nurse finds that a particular topic is making the patient uncomfortable and anxious. What should the nurse do? 1 Push for more information from the patient 2 Note the patient's anxiety regarding that topic 3 Make the patient continue to discuss the reason for his or her anxiety 4 Continue assessing but keep discussing that topic intermittently

2 Note the patient's anxiety regarding that topic A patient feeling overly anxious and uncomfortable about a particular topic is valuable information and should be noted during assessment. It would be better to abandon the topic because pushing for more information can increase the patient's embarrassment and anxiety. The patient may not feel comfortable to discuss the reasons for anxiety and can become more anxious. Continuing to discuss the topic can make the patient more anxious and uncomfortable.

A 43-year-old patient is being seen in the mental health clinic with depression. The patient states, "I have always been a practicing Jew, but in the past few months I am questioning everything. I just don't know if I believe in it anymore." Which nursing diagnosis best describes the patient's comment? 1 Hopelessness 2 Spiritual distress 3 Ineffective coping 4 Risk for self-harm

2 Spiritual distress The patient is expressing distress regarding religion and spiritual well-being. The patient could be experiencing ineffective coping, but this does not directly relate to his or her comment. There is nothing in the patient's comment that would lead to the conclusion the patient is having thoughts of harming him- or herself. The patient's comment does not describe hopelessness.

A nurse prepares to assess a newly admitted patient's spirituality. Which question will yield the most helpful information for care planning? 1 "When do you read the Bible?" 2 "What is your primary language?" 3 "What does spirituality mean to you?" 4 "Do you consider yourself a religious person?"

3 "What does spirituality mean to you?" Spirituality is an internal phenomenon related to universal human questions and needs. Spirituality has three dimensions: cognitive (beliefs, values, ideals, purpose, truth, wisdom), experiential (love, compassion, connection, forgiveness, altruism), and behavioral (daily behavior, moral obligations, life choices, and medical choices). Open-ended questions yield broad perspectives regarding patients' beliefs. Religion is an external system that includes beliefs, patterns of worship, and symbols. Closed-ended questions (those that can be answered "yes" or "no") yield less information. Assessing a patient's primary language applies to culture.

A nurse is assessing a 10-year-old child who is suspected of having emotional problems. Which methods does the nurse apply to obtain relevant information? 1 Interview and lab work 2 Observation and lab work 3 Interview and observation 4 Lab work and radiologic test

3 Interview and observation Children often show their emotions while playing, acting, or drawing; hence an interview along with observation of such activities is required. An interview can help in giving information but needs to be done with observation as children show their emotions through play. Observation can provide only information that can be perceived, but it should be applied with an interview for interaction. Assessment of children can be done better with an interview and observation than with lab work and radiologic examinations.

The mental status examination aids in the collection of what type of data? 1 Covert 2 Physical 3 Objective 4 Subjective

3 Objective The mental status examination mostly aids in the collection of objective data.

The primary source for data collection during a psychiatric nursing assessment is the patient's 1 Family and friends 2 Nonverbal responses 3 Own words and actions 4 Medical treatment records

3 Own words and actions The patient always should be considered the primary data source. At times, however, the patient will be unable to fulfill this role.

Which rating tool is used by the nurse when assessing a patient with schizophrenia? 1 Cognitive Capacity Screening Examination (CCSE) 2 Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) 3 Scale for Assessment of Negative Symptoms (SANS) 4 Recovery Attitude and Treatment Evaluator (RAATE)

3 Scale for Assessment of Negative Symptoms (SANS) Nurses and medical care professionals make use of several assessment tools for evaluation and monitoring of psychiatric disorders. The Scale for Assessment of Negative Symptoms is the assessment tool used for patients with schizophrenia. The Cognitive Capacity Screening Examination, Yale-Brown Obsessive-Compulsive Scale, and Recovery Attitude and Treatment Evaluator are not used for patients with schizophrenia. The Cognitive Capacity Screening Examination is used for cognitively impaired patients. The Yale-Brown Obsessive-Compulsive Scale is used for patients with obsessive-compulsive disorder. The Recovery Attitude and Treatment Evaluator is used for patients of substance use disorders.

A nurse is interviewing a new patient who is angry and highly suspicious. When asked about sexual orientation, the patient becomes highly distressed and threatens to walk out of the interview. The nurse responds, 1 "I would like you to stay and answer the question." 2 "Don't be concerned. I accept homosexuals as well as heterosexuals." 3 "Your distress leads me to believe you may have something you don't want to discuss." 4 "I can see that this topic makes you uncomfortable. We can defer discussion of it today."

4 "I can see that this topic makes you uncomfortable. We can defer discussion of it today." A cardinal rule of interviewing is "Don't probe sensitive areas." Patients are allowed to take the lead.

When assessing a mentally ill patient, a nurse finds that the patient has auditory hallucinations. In which category should the nurse consider this symptom during the mental status examination? 1 Speech problems 2 Cognitive disturbances 3 Behavioral disturbances 4 Perceptual disturbances

4 Perceptual disturbances Auditory hallucinations are considered perceptual disturbances as they affect the patient's perceptions. Cognitive disturbances involve problems with orientation, level of consciousness, memory, attention, abstraction, insight, and judgment. Behavioral disturbances include abnormal body movements or difference in eye contact. Speech problems involve impairment in rate and volume of speech.