Mental Health Chapter 7

Which statement made by the nurse concerning a client experiencing musculoskeletal pain demonstrates attention to the evaluation portion of the nursing process?

"After 2 weeks of physical therapy, the client can safely walk the length of the hallway."

What is a legally appropriate notation for the nurse to include in a client's medical record?

"Client asked 'Why aren't you helping me feel better?'"

Which question will the nurse ask the client during a psychosocial assessment to determine existing social patterns?

"Please describe your typical day."

A mental health nurse is administering a client medication and the client states, "I am not taking that pill and you can't make me." Which statement most accurately describes the nurse's obligation to the client who is demonstrating nonadherent behavior?

"The medication will help you relax. If it doesn't, we can talk about other options."

A nurse assesses a new client whose chief concern is "daily crying spells." Which comment from the client would prompt the nurse to suspect a medical reason is causing the problem rather than depression?

"Years ago I had thyroid problems, but they cleared up and I stopped the medicine."

A client from which demographic group is most likely to have concerns about confidentiality and need reassurance from the nurse during a clinical interview?

Adolescents

With respect to language barriers in health care settings, which statement is true about the difference between an interpreter and a translator?

An interpreter tries to make sense of what the person is saying; a translator avoids inserting his or her own understanding of the situation.

What are the advantages of narrative charting? Select all that apply.

Can address any event or behavior Explains flow sheet findings Uses a common form of expression

How is evidence-based practice most accurately defined?

Care that combines clinical skills with relevant research and is effective for each individual patient

What is the most appropriate long-term goal for a client with history of a suicide attempt and recent self-mutilation behaviors?

Client will remain free from self-inflicted injuries for the duration of the hospitalization.

A 75-year-old client diagnosed with dementia was found wandering a busy street and brought to the emergency department by police. What is the most effective way for the nurse to implement holistic data collection?

Conduct interviews with the client, the police, and appropriate family members and neighbors.

According to NANDA-I, which aspect of a standard nursing diagnosis is excluded in "risk for" diagnoses?

Defining characteristics

What structural components are part of a standard nursing diagnosis? Select all that apply.

Defining characteristics Supporting data Problem Etiology

Which standard of practice for psychiatric mental health nursing provides the focus for selecting therapeutic interventions and outcomes?

Diagnosis

On an inpatient unit, one client assaults another client, resulting in a small laceration. Considering both clients' rights to confidentiality, how will the nurse effectively document this event?

Document in each client's medical record the events and actions taken, using the initials of the other client involved.

What is considered the seventh step of nursing process?

Documentation

In a health promotion nursing diagnosis, which aspect of a standard nursing diagnosis is excluded?

Etiology

What role does etiology play in the nursing diagnosis and planning?

Etiology defines the likely causes of the nursing diagnosis and guides the plan of care for the individual client.

What is often the most neglected part of the nursing process?

Evaluation of client outcomes

A nurse uses recent reviews of current literature on the effectiveness of mindfulness-based therapies to determine whether or not to recommend these interventions to clients. Which term applies to the nurse's actions?

Evidence-based practice

Which data would be documented during a psychosocial assessment? Select all that apply.

Family health history Cultural and spiritual practices Substance abuse

An older adult client's spouse died 2 months ago. Since then, he has stopped bathing and changing his clothes regularly. He has expressed to the nurse that he is lonely and doesn't wish to live without his spouse. What nursing intervention is most appropriate for this client?

Help the client identify a support network of friends, family, and care providers.

The nurse is interviewing a client who immigrated from India. The nurse asks questions about the client's home culture and religious practices in addition to questions about medical history. What does this combination of questions most represent?

Holistic approach to care

Which standard of practice for psychiatric mental health nursing involves health teaching and promotion?

Implementation

The nurse plans care for a newly hospitalized client experiencing panic-level anxiety after an automobile accident. The client has no physical injuries. When selecting goals from the Nursing Outcomes Classification (NOC), what is the nurse's priority?

Individualize outcomes based on the client's needs.

The nurse is assessing a 9-year-old child. The child's parent reports that the child wakes up several times throughout the night crying. The nurse finds that the child has had multiple fractures over the past year. What is the nurse's most appropriate action?

Interview the child separately from the parents, so the child is less reluctant to give details about possible physical abuse.

What are the disadvantages of problem-oriented charting? Select all that apply.

Limits entries to problems Requires time and effort to structure the information May result in loss of data about progress

Which interventions are most appropriate for a basic level psychiatric mental health registered nurse (PMH-RN)? Select all that apply.

Managing the milieu by selecting activities for an adolescent group Assisting a client's family in identifying appropriate housing for their parent Presenting information on the special needs of the depressed to a family support group

Informing clients about their rights and responsibilities is an aspect of which nursing intervention?

Milieu therapy

Which statements are true about outcome criteria in nursing process? Select all that apply.

Outcomes provide direction for continuity of care. Outcomes are measurable and achievable through evidence-based interventions. Outcomes reflect desired changes related to the problem stated in the nursing diagnosis.

Which statement is true about depression and certain physical conditions?

People with coronary artery disease, diabetes, and stroke are at greater risk for depression than people without these conditions.

How can the use of clinical simulations in nursing and medical education be described?

Performance-based learning

Which standard of practice for psychiatric mental health nursing involves identifying evidence-based interventions?

Planning

A newly hospitalized client frequently becomes agitated and repeats "the fight, the fight" but will not elaborate. Which sources of information are most appropriate for the nurse to use to gain a clearer picture of this client? Select all that apply.

Police reports from the client's arrest history Medical records from previous psychiatric admission Emergency department records from the client's initial admission

As of the late 1990s, the Institute of Medicine found the United States lacking in which areas of health care? Select all that apply.

Quality care across geographic locations Services rooted in evidence-based practices Respectful, responsible, and patient-centered care

A 60-year-old client reports, "I stopped taking my medication shortly after it became unsafe for me to drive due to my health problems." What is the most appropriate action by the nurse?

Question the client about difficulty obtaining the medication.

What phrase should the nurse include in all nursing diagnoses related to health promotion?

Readiness for enhanced

A client has been undergoing treatment for abusing alcohol. During a reassessment by the nurse, the client states, "I know I can't be around alcohol and those friends right now. I'm strong enough now to understand my own weaknesses." What is the most relevant nursing diagnosis for this client?

Readiness for enhanced self-concept as evidenced by willingness to accept limitations and strengths.

Which statements are true about mental illness in children? Select all that apply.

Regression is a hallmark of psychiatric disorders in children Observing a child at play is an effective means of assessing psychiatric well-being.

A 55-year-old lives 100 miles from her parents and mother-in-law. In the past year, her father had back surgery, her mother broke her hip, and her mother-in-law had a cardiac event. Which nursing diagnosis is most applicable to the 55-year-old?

Risk for caregiver role strain related to responsibilities for care of aging parents

Planning nursing actions to achieve stated outcomes should include use of which principles? Select all that apply.

Safe Evidence-based Compatible with other therapies

Which rating scale is used in the evaluation and monitoring of schizophrenia?

Scale for Assessment of Negative Symptoms (SANS)

A 27-year-old client with history of bulimia has been using a razor to make small cuts on both legs. Which nursing diagnosis is most appropriate?

Self-mutilation with disturbed body image as evidenced by self-inflicted cutting and history of eating disorder

Which assessment data would the nurse expect to document after the administration of a mental status examination (MSE) on a client with no history of mental illness?

Speaks and presents information in an organized fashion

The mental status exam (MSE) aids in collecting which objective data? Select all that apply.

Speech patterns Appearance Perceptions

A client asks the psychiatric registered nurse, "I'm having so much anxiety. I think hypnosis would help me. Will you do that for me?" When determining a response, which factor should the nurse consider first?

State regulations regarding scope of practice

What do the "S" and "O" in the problem-oriented SOAPIE charting system represent?

Subjective and objective

A client reports having racing thoughts and feeling easily distracted. The nurse observes that the client talks fast and paces around the room. What blood tests does the nurse expect will be the priority to rule out a medical condition mimicking a psychiatric illness?

TSH and thyroxine

Which factors should be considered to ensure a plan of care is patient-centered? Select all that apply.

The available community resources and technology The client's capabilities given age, physical strength, and condition The client's willingness to change The client's preferences, health practices, and goals

Who is the nurse's primary source of information when completing a client's assessment?

The client

What information should the nurse document in the client's medical record? Select all that apply.

The client's expressed subjective feelings What the nurse sees, hears, feels, and smells What discharge teaching was performed Health care providers' visits and treatments

What is the main purpose of the mental status evaluation (MSE)?

To assess current cognitive processes

What is the primary goal of the Health Insurance Portability and Accountability Act (HIPAA)?

To ensure that an individual's health information is properly protected while receiving high-quality health care

What is the purpose of standardized rating scales for depression?

To evaluate and monitor severity of symptoms

What is one purpose of the psychosocial assessment?

To identify stressors and coping mechanisms

What is the primary goal of Quality and Safety Education for Nurses (QSEN)?

To prepare nurses with the knowledge, skills, and attitudes required to enhance quality, care, and safety in the health care setting

What characteristics define client outcomes? Select all that apply.

Variable Measurable Reflective of client's actual state