Chapter 07: The Nursing Process and Standards of Care for Psychiatric Mental Health Nursing

Which are the purposes of a thorough mental health nursing assessment? a. Establish a rapport between the nurse and patient. b. Assess for risk factors affecting the safety of the patient or others. c. Allow the nurse the chance to provide counseling to the patient. d. Identify the nurse's goals for treatment. e. Formulate a plan of care.

A, B, D, E

A patient begins a new program to assist with building social skills. In which part of the plan of care should a nurse record the item, "Encourage patient to attend one psychoeducational group daily"? a.Assessment c.Implementation b.Analysis d.Evaluation

ANS:C Interventions are the nursing prescriptions to achieve the outcomes. Interventions should be specific. PTS:1 DIF:Cognitive Level: Apply (Application) REF:Page 126-127 TOP:Nursing Process: Implementation MSC:Client Needs: Psychosocial Integrity

A nurse documents: "Patient is mute despite repeated efforts to elicit speech. Makes no eye contact. Inattentive to staff. Gazes off to the side or looks upward rather than at speaker." Which nursing diagnosis should be considered? a.Defensive coping c.Risk for other-directed violence b.Decisional conflict d.Impaired verbal communication

ANS:D The defining characteristics are more related to the nursing diagnosis of impaired verbal communication than to the other nursing diagnoses. PTS:1 DIF:Cognitive Level: Apply (Application) REF:Page 123-124 TOP:Nursing Process: Diagnosis/Analysis MSC:Client Needs: Psychosocial Integrity

Select the best outcome for a patient with the nursing diagnosis: Impaired social interaction related to sociocultural dissonance as evidenced by stating, "Although I'd like to, I don't join in because I don't speak the language very well." Patient will: a.show improved use of language. b.demonstrate improved social skills. c.become more independent in decision making. d.select and participate in one group activity per day.

ANS:D The outcome describes social involvement on the part of the patient. Neither cooperation nor independence has been an issue. The patient has already expressed a desire to interact with others. Outcomes must be measurable. Two of the distracters are not measurable. PTS:1 DIF:Cognitive Level: Analyze (Analysis) REF:Page 124 TOP:Nursing Process: Outcomes Identification MSC:Client Needs: Psychosocial Integrity

What is the common behavior shared by both client and nurse at the beginning of the initial assessment interview? a. Anxiety b. Biased perceptions c. Countertransference d. Reliance on supportive confrontation

A Both parties feel at least a small amount of anxiety associated with interacting with an unknown person. REF: Page 117-118

The client's priority nursing diagnosis has been established as risk for self-directed violence: suicide related to multiple losses. The priority outcome would be that the client will a. refrain from attempting suicide. b. be placed on suicide precautions. c. attend self-help group daily. d. state absence of feelings of powerlessness.

A Refraining from suicidal attempts is the only outcome that addresses the risk for self-directed violence. The absence of a feeling of powerlessness is not appropriate for the stated nursing diagnosis. The remaining options are interventions. REF: Page 124-125

The primary source for data collection during a psychiatric nursing assessment is the a. client's own words and actions. b. client's family and friends. c. client's nonverbal responses. d. client's medical treatment records.

A The client should always be considered the primary data source. At times, however, the client will be unable to fulfill this role. REF:118

When a nurse assesses an older adult patient, answers seem vague or unrelated to the questions. The patient also leans forward and frowns, listening intently to the nurse. An appropriate question for the nurse to ask would be: a."Are you having difficulty hearing when I speak?" b."How can I make this assessment interview easier for you?" c."I notice you are frowning. Are you feeling annoyed with me?" d."You're having trouble focusing on what I'm saying. What is distracting you?"

ANS:A The patient's behaviors may indicate difficulty hearing. Identifying any physical need the patient may have at the onset of the interview and making accommodations are important considerations. By asking if the patient is annoyed, the nurse is jumping to conclusions. Asking how to make the interview easier for the patient may not elicit a concrete answer. Asking about distractions is a way of asking about auditory hallucinations, which is not appropriate because the nurse has observed that the patient seems to be listening intently. PTS:1 DIF:Cognitive Level: Apply (Application) REF:Page 118-119 TOP:Nursing Process: Assessment MSC:Client Needs: Physiological Integrity

A nurse performing an assessment interview for a patient with a substance use disorder decides to use a standardized rating scale. Which scales are appropriate? Select all that apply. a.Addiction Severity Index (ASI) b.Brief Drug Abuse Screen Test (B-DAST) c.Abnormal Involuntary Movement Scale (AIMS) d.Cognitive Capacity Screening Examination (CCSE) e.Recovery Attitude and Treatment Evaluator (RAATE)

ANS:A, B, E Standardized scales are useful for obtaining data about substance use disorders. The ASI, B-DAST, and RAATE are scales related to substance abuse. AIMS assesses involuntary movements associated with anti-psychotic medications. The CCSE assesses cognitive function. PTS:1 DIF:Cognitive Level: Apply (Application) REF:Page 123 (Table 7-1) TOP:Nursing Process: Assessment MSC:Client Needs: Psychosocial Integrity

A nurse asks a patient, "If you had fever and vomiting for 3 days, what would you do?" Which aspect of the mental status examination is the nurse assessing? a.Behavior c.Affect and mood b.Cognition d.Perceptual disturbances

ANS:B Assessing cognition involves determining a patient's judgment and decision making. In this case, the nurse would expect a response of "Call my doctor" if the patient's cognition and judgment are intact. If the patient responds, "I would stop eating" or "I would just wait and see what happened," the nurse would conclude that judgment is impaired. The other options refer to other aspects of the examination. PTS:1 DIF:Cognitive Level: Apply (Application) REF:Page 121 (Box 7-4) TOP:Nursing Process: Assessment MSC:Client Needs: Psychosocial Integrity

Before assessing a new patient, a nurse is told by another health care worker, "I know that patient. No matter how hard we work, there isn't much improvement by the time of discharge." The nurse's responsibility is to: a.document the other worker's assessment of the patient. b.assess the patient based on data collected from all sources. c.validate the worker's impression by contacting the patient's significant other. d.discuss the worker's impression with the patient during the assessment interview.

ANS:B Assessment should include data obtained from both the primary and reliable secondary sources. The nurse, bearing in mind the possible effects of counter-transference, should evaluate biased assessments by others as objectively as possible. PTS:1 DIF:Cognitive Level: Apply (Application) REF:Page 117-118 TOP:Nursing Process: Assessment MSC:Client Needs: Safe, Effective Care Environment

A patient presents to the emergency department with mixed psychiatric symptoms. The admission nurse suspects the symptoms may be the result of a medical problem. Lab results show elevated BUN (blood urea nitrogen) and creatinine. What is the nurse's next best action? a.Report the findings to the health care provider. b.Assess the patient for a history of renal problems. c.Assess the patient's family history for cardiac problems. d.Arrange for the patient's hospitalization on the psychiatric unit.

ANS:B Elevated BUN (blood urea nitrogen) and creatinine suggest renal problems. Renal dysfunction can often imitate psychiatric disorders. The nurse should further assess the patient's history for renal problems and then share the findings with the health care provider. PTS:1 DIF:Cognitive Level: Analyze (Analysis) REF:Page 119-120 (Box 7-3) TOP:Nursing Process: Assessment MSC:Client Needs: Physiological Integrity

A new staff nurse completes an orientation to the psychiatric unit. This nurse will expect to ask an advanced practice nurse to perform which action for patients? a.Perform mental health assessment interviews. b.Prescribe psychotropic medication. c.Establish therapeutic relationships. d.Individualize nursing care plans.

ANS:B Prescriptive privileges are granted to master's-prepared nurse practitioners who have taken special courses on prescribing medication. The nurse prepared at the basic level performs mental health assessments, establishes relationships, and provides individualized care planning. Note that this question was also offered for Chapter 1. PTS:1 DIF:Cognitive Level: Understand (Comprehension) REF:Page 127 TOP:Nursing Process: Implementation MSC:Client Needs: Safe, Effective Care Environment

Which entry in the medical record best meets the requirement for problem-oriented charting? a."A: Pacing and muttering to self. P: Sensory perceptual alteration related to internal auditory stimulation. I: Given fluphenazine HCL (Prolixin) 2.5 mg po at 0900 and went to room to lie down. E: Calmer by 0930. Returned to lounge to watch TV." b."S: States, 'I feel like I'm ready to blow up.' O: Pacing hall, mumbling to self. A: Auditory hallucinations. P: Offer haloperidol (Haldol) 2 mg po. I: Haloperidol (Haldol) 2 mg po given at 0900. E: Returned to lounge at 0930 and quietly watched TV." c."Agitated behavior. D: Patient muttering to self as though answering an unseen person. A: Given haloperidol (Haldol) 2 mg po and went to room to lie down. E: Patient calmer. Returned to lounge to watch TV." d."Pacing hall and muttering to self as though answering an unseen person. haloperidol (Haldol) 2 mg po administered at 0900 with calming effect in 30 minutes. Stated, 'I'm no longer bothered by the voices.'"

ANS:B Problem-oriented documentation uses the first letter of key words to organize data: S for subjective data, O for objective data, A for assessment, P for plan, I for intervention, and E for evaluation. The distracters offer examples of PIE charting, focus documentation, and narrative documentation. PTS:1 DIF:Cognitive Level: Analyze (Analysis) REF:Page 127-128 (Table 7-4) TOP:Nursing Process: Implementation MSC:Client Needs: Safe, Effective Care Environment

A nurse wants to assess an adult patient's recent memory. Which question would best yield the desired information? a."Where did you go to elementary school?" b."What did you have for breakfast this morning?" c."Can you name the current president of the United States?" d."A few minutes ago, I told you my name. Can you remember it?"

ANS:B The patient's recall of a meal provides evidence of recent memory. Two incorrect responses are useful to assess immediate and remote memory. The other distracter assesses the patient's fund of knowledge. PTS:1 DIF:Cognitive Level: Apply (Application) REF:Page 121 (Box 7-4) TOP:Nursing Process: Assessment MSC:Client Needs: Psychosocial Integrity

After formulating the nursing diagnoses for a new patient, what is a nurse's next action? a.Designing interventions to include in the plan of care b.Determining the goals and outcome criteria c.Implementing the nursing plan of care d.Completing the spiritual assessment

ANS:B The third step of the nursing process is planning and outcome identification. Outcomes cannot be determined until the nursing assessment is complete and nursing diagnoses have been formulated. PTS:1 DIF:Cognitive Level: Understand (Comprehension) REF:Page 123-124 TOP:Nursing Process: Implementation MSC:Client Needs: Safe, Effective Care Environment

A patient is very suspicious and states, "The FBI has me under surveillance." Which strategiesshould a nurse use when gathering initial assessment data about this patient? Select all that apply. a.Tell the patient that medication will help this type of thinking. b.Ask the patient, "Tell me about the problem as you see it." c.Seek information about when the problem began. d.Tell the patient, "Your ideas are not realistic." e.Reassure the patient, "You are safe here."

ANS:B, C, E During the assessment interview, the nurse should listen attentively and accept the patient's statements in a nonjudgmental way. Because the patient is suspicious and fearful, reassuring safety may be helpful, although trust is unlikely so early in the relationship. Saying that medication will help or telling the patient that the ideas are not realistic will undermine development of trust between the nurse and patient. PTS:1 DIF:Cognitive Level: Apply (Application) REF:Page 120-121 (Box 7-4) TOP:Nursing Process: Assessment MSC:Client Needs: Psychosocial Integrity

A nurse assessed a patient who reluctantly participated in activities, answered questions with minimal responses, and rarely made eye contact. What information should be included when documenting the assessment? Select all that apply. a.The patient was uncooperative b.The patient's subjective responses c.Only data obtained from the patient's verbal responses d.A description of the patient's behavior during the interview e.Analysis of why the patient was unresponsive during the interview

ANS:B, D Both content and process of the interview should be documented. Providing only the patient's verbal responses would create a skewed picture of the patient. Writing that the patient was uncooperative is subjectively worded. An objective description of patient behavior would be preferable. Analysis of the reasons for the patient's behavior would be speculation, which is inappropriate. PTS:1 DIF:Cognitive Level: Apply (Application) REF:Page 117-118 | Page 127-128 (Box7-7) TOP:Nursing Process: Assessment MSC:Client Needs: Safe, Effective Care Environment

What information is conveyed by nursing diagnoses? Select all that apply. a.Medical judgments about the disorder b.Unmet patient needs currently present c.Goals and outcomes for the plan of care d.Supporting data that validate the diagnoses e.Probable causes that will be targets for nursing interventions

ANS:B, D, E Nursing diagnoses focus on phenomena of concern to nurses rather than on medical diagnoses. PTS:1 DIF:Cognitive Level: Understand (Comprehension) REF:Page 123-124 TOP:Nursing Process: Diagnosis/Analysis MSC:Client Needs: Safe, Effective Care Environment

An adolescent asks a nurse conducting an assessment interview, "Why should I tell you anything? You'll just tell my parents whatever you find out." Which response by the nurse is appropriate? a."That isn't true. What you tell us is private and held in strict confidence. Your parents have no right to know." b."Yes, your parents may find out what you say, but it is important that they know about your problems." c."What you say about feelings is private, but some things, like suicidal thinking, must be reported to the treatment team." d."It sounds as though you are not really ready to work on your problems and make changes."

ANS:C Adolescents are very concerned with confidentiality. The patient has a right to know that mostinformation will be held in confidence but that certain material must be reported or shared with the treatment team, such as threats of suicide, homicide, use of illegal drugs, or issues of abuse. The incorrect responses are not true, will not inspire the confidence of the patient, or are confrontational. PTS:1 DIF:Cognitive Level: Apply (Application) REF:Page 118 TOP:Nursing Process: Implementation MSC:Client Needs: Safe, Effective Care Environment

When a new patient is hospitalized, a nurse takes the patient on a tour, explains rules of the unit, and discusses the daily schedule. The nurse is engaged in: a.counseling. c.milieu management. b.health teaching. d.psychobiological intervention.

ANS:C Milieu management provides a therapeutic environment in which the patient can feel comfortable and safe while engaging in activities that meet the patient's physical and mental health needs. Counseling refers to activities designed to promote problem solving and enhanced coping and includes interviewing, crisis intervention, stress management, and conflict resolution. Health teaching involves identifying health education needs and giving information about these needs. Psychobiological interventions involve medication administration and monitoring response to medications. PTS:1 DIF:Cognitive Level: Understand (Comprehension) REF:Page 126-127 TOP:Nursing Process: Implementation MSC:Client Needs: Safe, Effective Care Environment

Select the most appropriate label to complete this nursing diagnosis: ___________ related to feelings of shyness and poorly developed social skills as evidenced by watching television alone at home every evening. a.Deficient knowledge c.Social isolation b.Ineffective coping d.Powerlessness

ANS:C Nursing diagnoses are selected based on the etiological factors and assessment findings, or evidence. In this instance, the evidence shows social isolation that is caused by shyness and poorly developed social skills. PTS:1 DIF:Cognitive Level: Apply (Application) REF:Page 123-124 TOP:Nursing Process: Diagnosis/Analysis MSC:Client Needs: Psychosocial Integrity

A newly admitted patient diagnosed with major depression has gained 20 pounds over a few months and has suicidal ideation. The patient has taken an antidepressant medication for 1 week without remission of symptoms. Select the priority nursing diagnosis. a.Imbalanced nutrition: more than body requirements b.Chronic low self-esteem c.Risk for suicide d.Hopelessness

ANS:C Risk for suicide is the priority diagnosis when the patient has both suicidal ideation and a plan to carry out the suicidal intent. Imbalanced nutrition, hopelessness, and chronic low self-esteem may be applicable nursing diagnoses, but these problems do not affect patient safety asurgently as would a suicide attempt. PTS:1 DIF:Cognitive Level: Analyze (Analysis) REF:Page 123-124 TOP:Nursing Process: Diagnosis/Analysis MSC:Client Needs: Psychosocial Integrity

The desired outcome for a patient experiencing insomnia is, "Patient will sleep for a minimum of 5 hours nightly within 7 days." At the end of 7 days, review of sleep data shows the patient sleeps an average of 4 hours nightly and takes a 2-hour afternoon nap. The nurse will document the outcome as: a.consistently demonstrated. c.sometimes demonstrated. b.often demonstrated. d.never demonstrated.

ANS:D Although the patient is sleeping 6 hours daily, the total is not one uninterrupted session at night. Therefore, the outcome must be evaluated as never demonstrated. See relationship to audience response question. PTS:1 DIF:Cognitive Level: Apply (Application) REF:Page 127 TOP:Nursing Process: Evaluation MSC:Client Needs: Physiological Integrity

Nursing behaviors associated with the implementation phase of nursing process are concerned with: a.participating in mutual identification of patient outcomes. b.gathering accurate and sufficient patient-centered data. c.comparing patient responses and expected outcomes. d.carrying out interventions and coordinating care.

ANS:D Nursing behaviors relating to implementation include using available resources, performing interventions, finding alternatives when necessary, and coordinating care with other team members. PTS:1 DIF:Cognitive Level: Understand (Comprehension) REF:Page 126-127 TOP:Nursing Process: Implementation MSC:Client Needs: Safe, Effective Care Environment

The desired outcome for a patient experiencing insomnia is, "Patient will sleep for a minimum of 5 hours nightly within 7 days." At the end of 7 days, review of sleep data shows the patient sleeps an average of 4 hours nightly and takes a 2-hour afternoon nap. What is the nurse's next action? a.Continue the current plan without changes. b.Remove this nursing diagnosis from the plan of care. c.rite a new nursing diagnosis that better reflects the problem. d.Examine interventions for possible revision of the target date.

ANS:D Sleeping a total of 5 hours at night remains a reasonable outcome. Extending the period for attaining the outcome may be appropriate. Examining interventions might result in planning an activity during the afternoon rather than permitting a nap. Continuing the current plan without changes is inappropriate. Removing this nursing diagnosis from the plan of care would be correct when the outcome was met and the problem resolved. Writing a new nursing diagnosis is inappropriate because no other nursing diagnosis relates to the problem. PTS:1 DIF:Cognitive Level: Apply (Application) REF:Page 127 TOP:Nursing Process: Evaluation MSC:Clien Needs: Physiological Integrity

A nurse prepares to assess a new patient who moved to the United States from Central America three years ago. After introductions, what is the nurse's next comment? a."How did you get to the United States?" b."Would you like for a family member to help you talk with me?" c."An interpreter is available. Would you like for me to make a request for these services?" d."Are you comfortable conversing in English, or would you prefer to have a translator present?"

ANS:D The nurse should determine whether a translator is needed by first assessing the patient for language barriers. Accuracy of the assessment depends on the ability to communicate in a language that is familiar to the patient. Family members are not always reliable translators. An interpreter may change the patient's responses; a translator is a better resource. PTS:1 DIF:Cognitive Level: Analyze (Analysis) REF:Page 118-119 TOP:Nursing Process: Assessment MSC:Client Needs: Psychosocial Integrity

A patient states, "I'm not worth anything. I have negative thoughts about myself. I feel anxious and shaky all the time. Sometimes I feel so sad that I want to go to sleep and never wake up." Which nursing intervention should have the highest priority? a.Self-esteem-building activities c.Sleep enhancement activities b.Anxiety self-control measures d.Suicide precautions

ANS:D The nurse would place a priority on monitoring and reinforcing suicide self-restraint because it relates directly and immediately to patient safety. Patient safety is always a priority concern. The nurse should monitor and reinforce all patient attempts to control anxiety, improve sleep patterns, and develop self-esteem, while giving priority attention to suicide self-restraint. MSC:Client Needs: Physiological Integrity PTS:1 DIF:Cognitive Level: Analyze (Analysis) REF:Page 124-125 (Table 7-2) | Page 125 (Table 7-3) TOP:Nursing Process: Planning MSC:Client Needs: Safe, Effective Care Environment

A nurse assesses an older adult patient brought to the emergency department by a family member. The patient was wandering outside saying, "I can't find my way home." The patient is confused and unable to answer questions. Select the nurse's best action. a.Record the patient's answers to questions on the nursing assessment form. b.Ask an advanced practice nurse to perform the assessment interview. c.Call for a mental health advocate to maintain the patient's rights. d.Obtain important information from the family member.

ANS:D When the patient (primary source) is unable to provide information, secondary sources shouldbe used, in this case, the family member. Later, more data may be obtained from other information sources familiar with the patient. An advanced practice nurse is not needed for this assessment; it is within the scope of practice of the staff nurse. Calling a mental health advocate is unnecessary. See relationship to audience response question. PTS:1 DIF:Cognitive Level: Apply (Application) REF:Page 118-119 | Page 122-123 TOP:Nursing Process: Assessment MSC:Client Needs: Safe, Effective Care Environment

The nurse records this entry in a patient's progress notes: Patient escorted to unit by ER nurse at 2130. Patient's clothing was dirty. In interview room, patient sat with hands over face, sobbing softly. Did not acknowledge nurse or reply to questions. After several minutes, abruptly arose, ran to window, and pounded. Shouted repeatedly, "Let me out of here." Verbal intervention unsuccessful. Order for stat dose 2 mg haloperidol PO obtained; medication administered at 2150. By 2215, patient stopped shouting and returned to sit wordlessly in chair. Patient placed on one-to-one observation. How should this documentation be evaluated? a.Uses unapproved abbreviations b.Contains subjective material c.Too brief to be of value d.Excessively wordy e.Meets standards

ANS:E This narrative note describes patient appearance, behavior, and conversation. It mentions that less-restrictive measures were attempted before administering medication and documents patient response to medication. This note would probably meet standards. A complete nursing assessment would be in order as soon as the patient is able to participate. Subjective material is absent from the note. Abbreviations are acceptable. PTS:1 DIF:Cognitive Level: Analyze (Analysis) REF:Page 127-128 (Table 7-4) | Page 128 (Box 7-7) TOP:Nursing Process: Evaluation MSC:Client Needs: Safe, Effective Care Environment

You are conducting an admission interview with Callie, who was raped 2 weeks ago. When you ask Callie about the rape, she becomes very anxious and upset and begins to sob. Your best course of actions would be to: A. push Callie gently for more information about the rape because you need to document this in her chart. B. acknowledge that the topic of the rape is upsetting to Callie and reassure her that it can be discussed at another time when she feels more comfortable. C. use silence as a therapeutic tool and wait until Callie is done sobbing to continue discussing the rape. D. reassure Callie that anything she says to you will remain confidential.

B The best atmosphere for conducting an assessment is one with minimal anxiety on the patient's part. If a topic causes distress, it is best to abandon the topic at that time. It is important not to pry or push for information that is difficult for the patient to discuss. The use of silence continues to expect the patient to discuss the topic now. Reassurance of confidentiality continues to expect the patient to discuss the topic now. Cognitive Level: Apply (Application) Nursing Process: Planning NCLEX: Psychosocial Integrity Text page: 117

What three structural components comprise a nursing diagnosis? a. Problem, outcome, intervention b. Problem, etiology, supporting data c. Unmet need, goal, outcome criterion d. Presenting symptom, treatment, goal

B The components of the nursing diagnosis are problem, etiology, and supporting data. REF:123

You are interviewing Jamie, a 17-year-old female patient. She confides that she has been thinking of ways to kill a female peer who is Jamie's rival for the volleyball team captain position. She asks you if you can keep it a secret. The most appropriate response for you to make is: A. "I will keep it a secret, but you and I need to discuss ways to deal with this situation appropriately without committing a crime." B. "Yes, I will keep it confidential. We have laws to protect patients' confidentiality." C. "Jamie, issues of this kind have to be shared with the treatment team and your parents." D. "Jamie, I will have to share this with the treatment team, but we will not share it with your parents."

C 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. Cognitive Level: Apply (Application) Nursing Process: Implementation NCLEX: Safe and Effective Care Environment Text page: 118

You are working in the emergency department when a 26-year-old male patient is brought in suffering from psychosis. The patient is unable to give any coherent history. The patient's best friend is with him and offers to give you information regarding the patient. Which of the following responses is appropriate? A. "I'm sorry, but I cannot take any information from you as it would violate confidentiality laws." B. "There is no need for that as I will call his primary care provider to obtain the information we need." C. "Yes, I will be happy to get any information and history that you can provide." D. "Yes, however, we will have to get a release signed from the patient for you to be able to talk with me."

C The friend is a secondary source of information that will be helpful since the patient is not able to give any history or information at this time. Confidentiality laws do not prohibit obtaining information from a secondary source. The friend can provide information and/or history immediately and may be able to relate events that happened just before coming to the hospital. A release would not be necessary to take information about the patient from a secondary source, and a psychotic patient would not be competent to sign a release. Cognitive Level: Apply (Application) Nursing Process: Assessment NCLEX: Safe and Effective Care Environment Text page: 117

The nurse best assesses the client's spiritual life by asking, a. "Do you practice a specific religion?" b. "To whom do you turn in times of crisis?" c. "Do you attend church regularly?" d. "What role does religion play in your life?"

D Asking the client to define the role of religion in their life allows for discussion related to the other topics. REF: Page 121-122

Which activity is NOT considered a purpose of the initial psychiatric assessment? a. Obtaining understanding of the current problem b. Identifying treatment goals c. Formulating a plan of care d. Evaluating the results of intervention

D At an initial assessment, no interventions would have taken place; hence evaluation is not a purpose of the initial contact. REF:117-118

Which response to a patient's question of why you need to conduct an assessment interview best explains its purpose? A. "I need to find out more about you and the way you think in order to best help you." B. "The assessment interview lets you have an opportunity to express your feelings." C. "You are able to tell me in detail about your past so that we can determine why you are experiencing mental health alterations." D. "We will be able to form a relationship together where we can discuss the current problems and come up with goals and a plan for treatment."

D Some of the purposes of the assessment interview are to establish rapport, learn more about the presenting issues, and form mutual goals and a plan for treatment. The other options do not appropriately explain the assessment purpose. Cognitive Level: Analyze (Analysis) Nursing Process: Assessment NCLEX: Psychosocial Integrity Text page: 119

A tool the novice nurse might refer to when writing treatment results criteria is the a. North American Nursing Diagnosis Association (NANDA). b. Joint Commission (formally JCAHO). c. Nursing Interventions Classification (NIC). d. Nursing Outcomes Classification (NOC).

D The Nursing Outcomes Classification is a publication used as a resource across the United States. REF:124-125

Which nursing diagnosis for a psychiatric client is correctly structured and worded? a. Hopelessness related to severe chronic depression b. Spiritual distress as evidenced by client stating "God has abandoned me because I'm a bad person" c. Defensive coping related to lack of insight associated with illicit drug use d. Imbalanced nutrition: less than body requirements related to poor self-concept as evidenced by reporting "I'm not worthy of eating"

D This diagnosis contains all the required components: problem statement, the etiology, and supporting data. REF: Page 123

The principle that is the basis of nursing outcome planning is a. individuals have the right to autonomy to make decisions that affect them. b. nursing interventions are designed to solve individuals' problems for them. c. the goal of nursing action is to create a dependency between the client and the caregiver. d. nurses have the best understanding of client problems and so they direct outcome selection.

A This is the only true statement. The nurse and the client should work collaboratively because each has knowledge to contribute to planning for the attainment of mutually derived outcomes. REF: Page 124-125

Interviewer anxiety during an assessment interview is most likely to be a result of a. the client's perception of the interviewer's ability to help. b. concern resulting from the need to form a relationship. c. the nurse's inability to decide on a plan of action. d. the cultural biases of both the client and the nurse.

A Whenever a client is in doubt about the helpfulness of the interviewer, anxiety is generated. The interviewer can "tune in" to the client's anxiety by empathy. REF: Page 116-117

The most likely factor to interfere with data collection in an initial assessment interview of an older adult is a. whether the client has any physical deficiencies. b. the interviewing nurse's level of anxiety. c. the presence of any countertransference. d. the nurse's attitudes about aging.

A While all the options can interfere, the most prevalent one affecting the data collected is any physical and/or cognitive deficiencies that client may possess. REF: Page 122-123

When interviewing an adolescent client, the nurse can expect the client to be most concerned about the issue of a. confidentiality. b. sexual orientation. c. substance use or abuse. d. family mental problems.

A Adolescents are often concerned that what they reveal to the nurse or health care team will be shared with parents. Confidentiality should be explained at the outset of the interview. REF: Page 118

High levels of anxiety and maladaptive behavior are seen a. in all areas in the health care setting. b. only in the psychiatric mental health setting. c. where death is a frequent outcome despite treatment. d. when the nurse and client have yet to establish a therapeutic relationship.

A Anxiety occurs whenever individuals are faced with unfamiliar circumstances or other threats to the self. The health care setting presents many possible threats to the self, such as illness, disability, surgery, and pain. REF:118

You are assessing a 6-year-old patient. When assessing a child's perception of a difficult issue, which methods of assessment are appropriate? SELECT ALL THAT APPLY. a. Engage the child in a specific therapeutic game. b. Ask the child to draw a picture. c. Provide the child with an anatomically correct doll to act out a story. d. Allow the child to tell a story.

A, B, C, D

"QSEN" refers to: a.Qualitative Standardized Excellence in Nursing b.Quality and Safety Education for Nurses c.Quantitative Effectiveness in Nursing d.Quick Standards Essential for Nurses

ANS: B QSEN represents national initiatives centered on patient safety and quality. The primary goal of QSEN is to prepare future nurses with the knowledge, skills, and attitudes to increase the quality, care, and safety in the health care setting in which they work. PTS:1 DIF:Cognitive Level: Remember (Knowledge) REF:Page 115-117 (Box 7-1) TOP:Nursing Process: N/A MSC:Client Needs: Safe, Effective Care Environment

A patient diagnosed with major depression has lost 20 pounds in one month, has chronic low self-esteem, and a plan for suicide. The patient has taken an antidepressant medication for 1 week. Which nursing intervention has the highest priority? a.Implement suicide precautions. b.Offer high-calorie snacks and fluids frequently. c.Assist the patient to identify three personal strengths. d.Observe patient for therapeutic effects of antidepressant medication.

ANS:A Implementing suicide precautions is the only option related to patient safety. The other options, related to nutrition, self-esteem, and medication therapy, are important but are not priorities. PTS:1 DIF:Cognitive Level: Analyze (Analysis) REF:Page 126-127 TOP:Nursing Process: Planning MSC:Client Needs: Safe, Effective Care Environment

Which statement made by a patient during an initial assessment interview should serve as the priority focus for the plan of care? a."I can always trust my family." b."It seems like I always have bad luck." c."You never know who will turn against you." d."I hear evil voices that tell me to do bad things."

ANS:D The statement regarding evil voices tells the nurse that the patient is experiencing auditory hallucinations and may create risks for violence. The other statements are vague and do not clearly identify the patient's chief symptom. PTS:1 DIF:Cognitive Level: Analyze (Analysis) REF:Page 117 | Page 120-121 TOP:Nursing Process: Assessmen

At what point in an assessment interview would a nurse ask, "How does your faith help you in stressful situations?" During the assessment of: a.childhood growth and development c.educational background b.substance use and abuse d.coping strategies

ANS:D When discussing coping strategies, the nurse might ask what the patient does when upset, what usually relieves stress, and to whom the patient goes to talk about problems. The question regarding whether the patient's faith helps deal with stress fits well here. It would be out of place if introduced during exploration of the other topics. PTS:1 DIF:Cognitive Level: Apply (Application) REF:Page 120-121 (Box 7-5) TOP:Nursing Process: Assessment MSC:Client Needs: Psychosocial Integrity

A 43-year-old female patient is brought to the emergency department with complaints of bizarre speech, visual hallucinations, and changes in behavior. She has no psychiatric history. Before ordering a psychiatric consultation, the emergency room physician orders a battery of blood tests as well as an MRI of the brain. The rationale for this is: a. To avoid a lawsuit. b. Medical conditions and physical illness may mimic psychiatric illnesses; therefore, physical causes of symptoms must be ruled out. c. Emergency room physicians are required to order a certain number of tests for the emergency room visit to be reimbursed. d. To comply with hospital standards of care.

B

You are performing a spiritual assessment on a patient. Which patient statement would indicate that there is an experiential concern in the patient's spiritual life? a. "I really believe that my spouse loves me." b. "My sister will never forgive me for what I did." c. "I try to find time every day to pray, even though it's not easy." d. "I am happy with my life choices, even if my mother is not."

B

During the initial assessment interview with a psychiatric client, the nurse should regard the spiritual assessment as a. optional. b. important to complete. c. less relevant than the cultural assessment. d. relevant only when the client is oriented.

B For many clients, religious or spiritual practices are an important part of the quality of their lives. Nurses should support the spiritual dimension of the person. To do so, assessment is necessary. REF:120-121

Joel is a 43-year-old patient being seen in the mental health clinic with depression. Joel 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 of the following nursing diagnoses best describes Joel's comment? A. Ineffective coping B. Spiritual distress C. Risk for self-harm D. Hopelessness

B Joel is expressing distress regarding his religion and spiritual well-being. Joel could be experiencing ineffective coping, but this does not directly relate to his comment. There is nothing in Joel's comment that would lead to the conclusion the patient is having thoughts of harming himself. Joel's comment does not describe hopelessness. Cognitive Level: Analyze (Analysis) Nursing Process: Diagnosis NCLEX: Psychosocial Integrity Text page: 117

In psychiatric nursing, assessment of a "client" refers exclusively to a. an individual with a psychiatric diagnosis. b. an individual, family, group, or community. c. any person who seeks the assistance of the psychiatric nurse. d. the person identified by the system as being in need of treatment.

B Standards of practice for psychiatric nursing indicate that the client can be an individual, a family, a group, or a community. REF:117

A nurse is about to interview a client whose glasses and hearing aid were placed in safe-keeping when she was admitted. Before beginning the interview, the nursing intervention that will best facilitate data collection is to a. ask the client if she needs her glasses and hearing aid. b. give the client her glasses and hearing aid. c. assist the client in putting on glasses and hearing aid. d. explain the importance of wearing her hearing aid and glasses.

C A client whose hearing or sight is impaired may have difficulty providing information if these items have been removed from his or her possession. Assisting the client in wearing these assistive devices is the best initial intervention. REF: Page 118-119

The mental status examination aids in the collection of what type of data? a. Covert b. Physical c. Objective d. Subjective

C The mental status exam mostly aids in the collection of objective data. REF:120-121

The nurse best ensures appropriate client care when choosing an intervention from a Nursing Interventions Classification that matches both a. the condition's etiology and the client's symptomatology. b. the nursing diagnosis and the condition's etiology. c. the defining data and the nursing diagnosis. d. the medical diagnosis and the nursing diagnosis.

C When choosing nursing interventions from the Nursing Interventions Classification or some other source, the nurse selects interventions that fit the nursing diagnosis (e.g., risk for suicide) and that match the defining data. REF:126-127

A patient states he has "given up on life." His wife left him, he was fired from his job, and he is four payments behind on his mortgage, meaning he will soon lose his house. Which nursing diagnosis is appropriate? a. Anxiety related to multiple losses. b. Defensive coping related to multiple losses. c. Ineffective denial related to multiple losses. d. Hopelessness related to multiple losses.

D

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

D A cardinal rule of interviewing is "Don't probe sensitive areas." Clients are allowed to take the lead. REF: Page 117-118

Which criterion is NOT essential when the nurse plans nursing interventions designed to meet a specific goal? a. Safe b. Evidence based c. Individualized d. Economical

D Although expense should be considered, interventions are chosen based on the other options and not on their economic value. REF:124-125