PrepU Chapter 10 The Psychiatric Mental Health Nursing Process
Which question is most appropriate for the nurse to ask in assessing a client's ability to concentrate with the mental status exam?
"Can you subtract five from 100 and continue until reaching 50?"
A client has learned about conflict resolution. Which statement made by the client to the nurse would indicate a need for further teaching?
"Conflict is always a negative situation where individuals both have to compromise."
The nurse is performing an initial assessment for a client newly admitted to the behavioral health unit. When initiating the assessment, which question will the nurse ask to obtain the most relevant data?
"Discuss with me what brought you in to the behavioral health unit today?"
The nurse is performing an initial assessment for a client newly admitted to the behavioral health unit. When initiating the assessment, which question will the nurse ask to obtain the most relevant data?
"Discuss with me what brought you in to the behavioral health unit today?" The nurse should use open-ended questions when gathering assessment data from the client. Doing so allows the client to begin as they feel comfortable and also gives the nurse an idea about the client's perception of their situation. When asking the client to discuss what brought them to the unit, an opportunity exists to discover more information. The other questions asked are closed-ended, do not elicit more information, and can be responded to in a yes or no response.
A client who is being admitted to a psychiatric unit explains the reason for seeking admission is related to the recent death of a young adult child. Which response by the nurse would enhance the effectiveness of this interview?
"How did you get through other close family member deaths?"
The nurse is assessing a client's abstract reasoning. Which statement made by the nurse to the client would elicit the most acccurate information regarding this clinical feature?
"People in glass houses should not throw stones."
A psychiatric-mental health nurse is assessing a client. Which statement by a client would the nurse recognize as evidence of an absence of insight?
"Sometimes I feel like the world would be better off if I were dead."
A client is crying while talking about a distressing situation. The nurse states to the client, "That must be very upsetting for you." Which assessment interview behavior is the nurse demonstrating?
exhibiting empathy
The nurse is interviewing a client admitted with a diagnosis of depression. What question asked by the nurse best indicates interest and establishes rapport with the client?
"Tell me what a routine day would be for you?" Asking a client what a routine day looks like is an open-ended question that allows the nurse to establish rapport and show interest in what a client's life is like. The other questions can elicit information but would be closed questions which would likely just have a short answer or one that would not encourage further discussion with the client.
A client states to the charge nurse, "I am so excited about my family coming to visit." The client is smiling and laughing. When the client walks away, a staff nurse asks about the client's behavior. Which is the appropriate response by the charge nurse?
"The client is going to have visitors, and this is causing euphoria."
A client states to the charge nurse, "I am so excited about my family coming to visit." The client is smiling and laughing. When the client walks away, a staff nurse asks about the client's behavior. Which is the appropriate response by the charge nurse?
"The client is going to have visitors, and this is causing euphoria." The nurse would indicate to the new nurse that the client is exhibiting a euphoric mood, which means being elated, expressing excitement, and smiling and laughing. If a client's mood is described as euthymic, this is considered normal. A client exhibiting a dysphoric mood appears depressed, disquieted, or restless. The client with a labile mood is exhibiting a changeable mood that varies widely over a short period of time.
A client's nursing diagnosis of "risk for self-directed violence" has been identified because of her recent history of cutting and self-mutilation. Which of the following expected outcomes is most appropriate for this client's plan of care during inpatient treatment?
"The client will refrain from cutting or self-mutilation."
The psychiatric nurse is caring for a client with mental illness. What statement from the client indicates that teaching on expected outcomes has been effective?
"The outcomes for my health should be measurable and realistic."
A client in an inpatient mental health unit is allowed to go to all areas of the unit open to clients during the day. What therapeutic intervention does this demonstrate?
privilege system
The nurse is assessing the client's cognition and intellectual performance. Which statement assesses abstract reasoning?
"What is the meaning of 'A penny saved is a penny earned'?"
The psychiatric nurse is interviewing a new client. The psychiatric nurse teaches the client to reflect on one's own personal-identity. Which client statement reflects that the client is determining personal-identity?
"What words would I use to describe who I am?"
A nurse is obtaining a client history and the client states "I am always being followed by someone." Which question demonstrates the interview behavior of reflection by the nurse?
"You feel that you are always being followed by someone?"
The nurse is interviewing a client who has a diagnosis of panic disorder. Which statement by the nurse indicates the use of summarizing?
"You have had several stressful events occur."
A client states "I am having trouble going to sleep." Which interventions would the nurse recommend that will be most beneficial to assist with sleep? Select all that apply.
- Avoid stimulating drinks such as coffee or tea in the evening - Limit fluid intake before bedtime - Establish a consistent bedtime routine
In assessing the client's cognition in a mental health assessment, which area(s) would be tested? Select all that apply.
- attention & concentration - judgment - short term memory
The nurse is teaching a client about a new psychotropic medication that the client will begin. Place the following steps in order for performance of the client's education.
1. Assess the client's knowledge of the medication & identify the client's learning style 2. Develop mutually agreed on goals with the client for learning about the medication 3. Instruct the client on administration needs and side effects of the medications. 4. Ask the client to explain how to administer the medications, & side effects to observe.
A client describes the recent breakup of a dating relationship when being interviewed by the nurse. Which finding will the nurse determine is the client's affect?
An emotionless tone and flat facial expression
If the client provides a literal explanation of a proverb and cannot interpret its meaning, which thought process is lacking?
Abstract thinking
The nurse is assessing which of the following when he asks the client to interpret a common proverb?
Abstract thinking
When completing a physical assessment of an individual's response to stress, the nurse should observe and inquire about what?
Appetite and sleep
The nurse notes that an older adult client is wearing layers of clothing on a warm, fall day. Which would be the priority assessment at this time?
Asking whether the client often feels cold
A client is admitted to the psychiatric unit and states, "I am president of the largest corporation in the world. Everyone comes to me for advice." Which behavior does the nurse document the client is exhibiting?
Delusion
A client states, "I don't want to eat anything because I am afraid that my food is poisoned." Which intervention is best for the nurse to perform to encourage the client to eat?
Encourage the client to help with meal preparation. The client who demonstrates paranoia about food being poisoned should be encouraged to help with food preparation so that there is certainty about food being not poisoned. Discussing nutrition, taking vitamins and adding favorite foods will not address the feeling of paranoia the client has about the food being poisoned.
A nurse has been asked to complete a mental status examination of a psychiatric-mental health client. Which is a necessary component of this assessment?
Evaluation of insight and judgment
A nurse is completing an assessment interview, and is attempting to bring the conversation back to the questions at hand when the client goes off on a tangent. Which assessment interview behavior is the nurse using?
Focusing
A nurse develops a plan of care for a client with an eating disorder. The plan includes developing a contract with the client to modify behavior. What is the next step?
Implement nursing actions that have been identified
A nurse awaits the arrival of a client who is being transferred from a nursing home. The client has a history of schizophrenia and has been behaving bizarrely. The nurse begins preparing the plan of care by outlining expected outcomes. The nurse's actions are which of the following?
Inconsistent with the nursing process, because assessment always comes first
A client being counseled for anger management has threatened to kill one of their family members by stabbing them. What is the nurse's priority intervention?
Inform the health care team and family member of the threats.
A client with a history of schizophrenia states "I am the ruler of a magical land." When the nurse replies by stating who and where the client is, which interview behavior is the nurse using?
Presenting reality
The nurse is performing a mental status assessment for a client with schizophrenia. The client begins talking in unconnected words that convey no meaning to the nurse. How will the nurse document this in the assessment?
The client is speaking in a word salad.
A nurse is viewing laboratory values for a client on psychotropic drugs who has elevated BUN (blood urea nitrogen) and serum creatinine levels. Why should the nurse be concerned regarding these laboratory values?
The client may be at risk for toxicity from the medication.
Which of the following represents a realistic measurable outcome for a client with schizophrenia?
The client will wash daily and come to the dining hall at dinner time.
Because of his fear of poisoning, a client with a diagnosis of schizophrenia has severely limited his food intake over the past several months, causing a weight loss of nearly 40 pounds. What consideration would be the priority in the planning of this client's care?
The client's nutritional status
When conducting a psycho-social assessment, the nurse inquires about the client's social supports. In order to effectively do this, which does the nurse need to explore?
The length and quality of relationships
A nurse is conducting a mental status examination on a client diagnosed with severe depression. The nurse asks the client to repeat the days of the week backward. What component of the examination is the nurse assessing in the client?
ability to concentrate
A nurse is conducting a mental status examination on a client diagnosed with severe depression. The nurse asks the client to repeat the days of the week backward. What component of the examination is the nurse assessing in the client? You Selected:
ability to concentrate
Which intervention uses the reading of written materials to express feelings or gain insight?
bibliotherapy
A nurse is caring for a client who has automatic thought patterns that interfere with the client's ability to function optimally. What type of intervention would the nurse anticipate be initiated with the client?
cognitive
A psychiatric-mental health nurse is gathering psychosocial assessment data from a client experiencing anxiety. Upon assessment, the client is restless and cannot concentrate on answering the questions from the nurse. What is the priority intervention from the nurse before proceeding in the interview?
decreasing the client's anxiety level
A client states to the nurse "I am so excited about my family coming to visit" and is smiling and laughing. How will the nurse document the client's mood?
euphoric
A client being counseled states to the nurse, "I am so stressed all the time. I live paycheck to paycheck." Which aspect of the client's well-being needs to be assessed further by the nurse?
financial
The nurse is caring for a client who states, "the FBI is listening, and they are going to come get me." Although the client is smiling at the nurse, the client is seen pacing the unit and checking the doors. How would the nurse document the client's affect?
inappropriate
A client reported to the nurse that on the client's way to the clinic, a police officer in a patrol car turned on the car's lights and pulled the client over. When asked what the client did next, the client stated, "I pulled over, of course." Which was the nurse trying to assess?
judgment
What is a nursing intervention used in the social domain?
milieu therapy
Upon assessment, the nurse notes that they client is using made-up words that have meaning only to the client. How would the nurse document these findings?
neologisms
A home health nurse is documenting and meeting with their supervisor about the client's home visit. Which phase of the home visit does the nurse identify that includes documentation and reporting?
postvisit
What is part of the social component in a psychiatric-mental health nursing assessment?
quality of life
Mrs. Yamada has been admitted to the psychiatric unit because of her worsening diagnosis of major depression that has not responded appreciably to treatment. In light of Mrs. Yamada's statement that "everything would be better if I was just dead and gone," the nurse would be justified in identifying what type of nursing diagnosis related to suicide?
risk nursing diagnosis
During an assessment, which would be the most important question topic?
suicidal ideation
The nurse states to a client who calls out for help, "I am happy to help you. Please let me know what I can do." Which process is the nurse using with this statement?
validation
