PSYCH CHAPTER 7 PRE AND POST TEST QUESTIONS AND NCLEX

A 17-year-old patient confides to the nurse that they have been thinking of ways to kill a peer. What response should the nurse give when the patient states, "you have to keep it a secret because its confidential information"? "I will keep it a secret, but you and I need to discuss ways to deal with this situation appropriately without committing a crime." "Yes, I will keep it confidential. We have laws to protect patients' confidentiality." "Issues of this kind have to be shared with the treatment team and your parents." "I will have to share this with the treatment team, but we will not share it with your parents."

"Issues of this kind have to be shared with the treatment team and your parents."

Which tool can the novice nurse might refer to when writing nursing outcomes? North American Nursing Diagnosis Association (NANDA) Joint Commission (formally JCAHO) Nursing Interventions Classification (NIC) Nursing Outcomes Classification (NOC)

Nursing Outcomes Classification (NOC)

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

Objective

What three structural components comprise a nursing diagnosis? Problem, outcome, intervention Problem, related factors, defining characteristics Unmet need, goal, outcome criterion Presenting symptom, treatment, goal

Problem, related factors, defining characteristics

Which response should the nurse provide a client who asks, "Why you need to conduct an assessment interview"? "I need to find out more about you and the way you think in order to best help you." "The assessment interview lets you have an opportunity to express your feelings." "You are able to tell me in detail about your past so that we can determine why you are experiencing mental health alterations." "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."

"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."

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

"What role does religion play in your life?"

A 26-year-old patient is brought to the emergency room by a friend. The patient is unable to give any coherent history. Which response should the nurse provide when the patient's friend offers to provide information regarding the patient? "I'm sorry, but I cannot take any information from you as it would violate confidentiality laws." "There is no need for that as I will call his primary care provider to obtain the information we need." "Yes, I will be happy to get any information and history that you can provide." "Yes, however, we will have to get a release signed from the patient for you to be able to talk with me."

"Yes, I will be happy to get any information and history that you can provide."

The nurse is conducting an admission interview with a client who was raped 2 weeks ago. When asked about the rape, the client becomes very anxious and upset and begins to sob. What should be the nurse's response to the client's reaction? Push gently for more information about the rape because the information needs to be documented. Acknowledge that the topic of the rape is upsetting and reassure the client that it can be discussed at another time when she feels more comfortable. Use silence as a therapeutic tool and wait until the client is done sobbing to continue discussing the rape. Reassure the client that anything she says to you will remain confidential.

Acknowledge that the topic of the rape is upsetting and reassure the client that it can be discussed at another time when she feels more comfortable.

A nurse is about to interview an older client whose glasses and hearing aid were placed in the bedside drawer for safe keeping. Before beginning the interview, which nursing intervention that will best facilitate data collection? Ask the client if she needs her glasses and hearing aid. Give the client her glasses and hearing aid. Assist the client in putting on glasses and hearing aid. Explain the importance of wearing her hearing aid and glasses.

Assist the client in putting on glasses and hearing aid.

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

Imbalanced nutrition: less than body requirements related to poor self-concept as evidenced by reporting "I'm not worthy of eating"

What principle forms the basis of nursing outcome planning? Individuals have the right to outcomes that is reflective of their abilities. Nursing interventions are designed to solve individuals' problems for them. The goal of nursing action is to create a dependency between the client and the caregiver. Nurses have the best understanding of client problems and so they direct outcome selection.

Individuals have the right to outcomes that is reflective of their abilities.

The client's priority nursing diagnosis has been established as risk for self-directed violence: suicide related to multiple losses. What is the priority outcome for this client? Refrain from attempting suicide. Be placed on suicide precautions. Attend self-help group daily. State absence of feelings of powerlessness.

Refrain from attempting suicide.

Which criterion is essential when the nurse plans nursing interventions designed to meet a specific goal? SATA Safe Evidence based Individualized Economical Realistic

Safe Evidence based Individualized Realistic

A 43-year-old client being seen in the mental health clinic 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 the client's comment? Ineffective coping Spiritual distress Risk for self-harm Hopelessness

Spiritual distress

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

client's own words and actions.