Chapter 6. The Nursing Process in Psychiatric/Mental Health Nursing

Multiple Choice

1. Which statement is most accurate regarding the assessment of clients diagnosed with psychiatric problems?

1. Medical history is of little significance and can be eliminated from the nursing assessment.

2. Assessment provides a holistic view of the client, including biopsychosocial aspects.

3. Comprehensive assessments can be performed only by advanced practice nurses.

4. Psychosocial evaluations are gained by subjective reports rather than objective observations.

ANS: 2

Rationale: The assessment of clients diagnosed with psychiatric problems should provide a holistic view of the client. A thorough assessment involves collecting and analyzing data from the client, significant others, and health-care providers, which may include the following dimensions: physical, psychological, sociocultural, spiritual, cognitive, functional abilities, developmental, economic, and lifestyle.

Cognitive Level: Application

Integrated Process: Assessment

2. Which statement regarding nursing interventions should a nurse identify as accurate?

1. Nursing interventions are independent from the treatment teams goals.

2. Nursing interventions are solely directed by written physician orders.

3. Nursing interventions occur independently but in concert with overall treatment team goals.

4. Nursing interventions are standardized by policies and procedures.

ANS: 3

Rationale: The nurse should understand that nursing interventions occur independently but in concert with overall treatment goals. Nursing interventions should be developed and implemented in collaboration with other health-care professionals involved in the clients care.

Cognitive Level: Application Integrated Process: Implementation

3. Within the nurses scope of practice, which function is exclusive to the advanced practice psychiatric nurse?

1. Teaching about the side effects of neuroleptic medications

2. Using psychotherapy to improve mental health status

3. Using milieu therapy to structure a therapeutic environment

4. Providing case management to coordinate continuity of health services

ANS: 2

Rationale: The advanced practice psychiatric nurse is authorized to use psychotherapy to improve mental health. This includes individual, couples, group, and family psychotherapy. Education, case management, and milieu therapy can be provided by registered psychiatric mental health nurses.

Cognitive Level: Application

Integrated Process: Implementation

4. The nurse should recognize which acronym as representing problem-oriented charting?

1. SOAPIE

2. APIE

3. DAR

4. PQRST

ANS: 1

Rationale: The acronym SOAPIE represents problem-oriented charting, which reflects the subjective, objective, assessment, plan, implementation, and evaluation format. Used in nursing, nursing diagnoses (problems) are identified on a written plan of care, with appropriate nursing interventions described for each.

Cognitive Level: Comprehension

Integrated Process: Implementation

5. Which tool would be appropriate for a nurse to use when assessing mental acuity prior to and immediately following electroconvulsive therapy (ECT)?

1. CIWA scale

2. GGT

3. MMSE

4. CAPS scale

ANS: 3

Rationale: The MMSE, or mini mental status exam, would be the appropriate tool to use to assess the mental acuity of a client prior to and immediately following ECT. The CIWA scale, or clinical institute withdrawal assessment scale, would be used to assess withdraw from substances such as alcohol. The CAPS refers to the clinician-administered PTSD scale and would be used to assess signs and symptoms of PTSD. The GGT test is a blood test used to assess gammaglutamyl transferase levels, which may be an indication of alcoholism.

Cognitive Level: Application

Integrated Process: Assessment

6. What is being assessed when a nurse asks a client to identify name, date, residential address, and situation?

1. Mood

2. Perception

3. Orientation

4. Affect

ANS: 3

Rationale: The nurse should ask the client to identify name, date, residential address, and situation to assess the clients orientation. Assessment of the clients orientation to reality is part of a mental status evaluation.

Cognitive Level: Application

Integrated Process: Assessment

7. What is the purpose of a nurse gathering client information?

1. It enables the nurse to modify behaviors related to personality disorders.

2. It enables the nurse to make sound clinical judgments and plan appropriate care.

3. It enables the nurse to prescribe the appropriate medications.

4. It enables the nurse to assign the appropriate Axis I diagnosis.

ANS: 2

Rationale: The purpose of gathering client information is to enable the nurse to make sound clinical judgments and plan appropriate care. The nurse should complete a thorough assessment of the client, including information collected from the client, significant others, and health-care providers.

Cognitive Level: Application Integrated Process: Assessment

8. A nurse on an inpatient psychiatric unit implements care by scheduling client activities, interacting with clients, and maintaining a safe therapeutic environment. These actions reflect which role of the nurse?

1. Health teacher

2. Case manager

3. Milieu manager

4. Psychotherapist

ANS: 3

Rationale: The milieu manager implements care by scheduling client activities, interacting with clients, and maintaining a safe therapeutic environment. Health teaching involves promoting health in a safe environment. Case management is used to organize client care so that outcomes are achieved. Psychotherapy involves conducting individual, couples, group, and family counseling.

Cognitive Level: Application Integrated Process: Implementation

9. The following outcome was developed for a client: Client will list five personal strengths by the end of day one. Which correctly written nursing diagnostic statement most likely generated the development of this outcome?

1. Altered self-esteem R/T years of emotional abuse AEB self-deprecating statements

2. Self-care deficit R/T altered thought process

3. Disturbed body image R/T major depressive disorder AEB mood rating of 2/10

4. Risk for disturbed self-concept R/T hopelessness AEB suicide attempt

ANS: 1

Rationale: The nurse should determine that altered self-esteem and self-deprecating statements would generate the outcome to list personal strengths by the end of day one. Self-care deficit, disturbed body image, and risk for disturbed self-concept would generate specific outcomes in accordance with specific needs and goals. The self-care deficit and risk for disturbed self-concept nursing diagnoses are incorrectly written.

Cognitive Level: Application

Integrated Process: Diagnosis

10. How should a nurse prioritize nursing diagnoses?

1. By the established goal of care

2. By the life-threatening potential

3. By the physicians priority of care

4. By the clients preference

ANS: 2

Rationale: The nurse should prioritize nursing diagnoses related to their life-threatening potential. Safety is always the nurses first priority.

Cognitive Level: Analysis

Integrated Process: Diagnosis

11. A client has a nursing diagnosis of Insomnia R/T paranoid thinking AEB MNA, DFA, and daytime napping. Which is a correctly written and appropriate outcome for this client?

1. The client will avoid daytime napping and attend all groups.

2. The client will exercise, as needed, before bedtime.

3. The client will sleep seven uninterrupted hours by day four of hospitalization.

4. The clients sleep habits will improve during hospitalization.

ANS: 3

Rationale: The outcome The client will sleep seven uninterrupted hours by day four of hospitalization is accurately written and an appropriate outcome for a client diagnosed with insomnia. Nursing outcomes should be derived from the diagnosis, measurable, and include a time estimate for attainment. The outcome must also be realistic for the clients capabilities.

Cognitive Level: Analysis

Integrated Process: Planning

12. The following NANDA-I nursing diagnostic stem was developed for a client on an inpatient unit: Risk for injury. What assessment data most likely led to the development of this problem statement?

1. The client is receiving ECT and is diagnosed with Parkinsonism.

2. The client has a history of four suicide attempts in adolescence.

3. The client expresses hopelessness and helplessness and isolates self.

4. The client has disorganized thought processes and delusional thinking.

ANS: 1

Rationale: The nurse should identify that a client receiving ECT and who is diagnosed with Parkinsonism is at risk for injury. History of suicide, hopelessness, and disorganized thoughts would not lead the nurse to formulate a nursing diagnostic stem of Risk for injury.

Cognitive Level: Application

Integrated Process: Assessment

13. A student nurse asks an instructor how best to develop nursing outcomes for clients. Which response by the instructor most accurately answers the students question?

1. You can use NIC, a standardized reference for nursing outcomes.

2. Look at your clients problems and set a realistic, achievable goal.

3. With client collaboration, outcomes should be based on client problems.

4. Copy your standard outcomes from a nursing care plan textbook.

ANS: 3

Rationale: Client outcomes are most realistic and achievable when there is collaboration among the interdisciplinary team members, the client, and significant others.

Cognitive Level: Application

Integrated Process: Planning

14. A client diagnosed with schizophrenia is exhibiting nonverbal behaviors indicating that the client is hearing things that others do not. Which nursing diagnosis, which was recently removed from the NANDA-I list, still accurately reflects this clients problem?

1. Disturbed thought processes

2. Disturbed sensory perception

3. Anxiety

4. Chronic confusion

ANS: 2

Rationale: The nursing diagnosis disturbed sensory perception accurately reflects the clients symptoms of hearing things that others do not. The nursing diagnosis describes the clients condition and facilitates the prescription of interventions.

Cognitive Level: Application

Integrated Process: Diagnosis

Multiple Response

15. Which of the following nursing interventions fall within the standards of psychiatricmental health clinical nursing practice for a nurse generalist? (Select all that apply.)

1. Assist the client to perform activities of daily living.

2. Consult with other clinicians to provide services for clients and effect system change.

3. Encourage the client to discuss triggers for relapse.

4. Use prescriptive authority in accordance with state and federal laws.

5. Educate the family about signs and symptoms of alcohol dependence and withdrawal.

ANS: 1, 3, 5

Rationale: Assisting the client to perform daily living activities, encouraging the client to discuss triggers, and educating the family are nursing interventions that fall within the standards of psychiatric clinical nursing practice for a nurse generalist. Psychiatricmental health advanced practice registered nurses can consult with other clinicians and use prescriptive authority.

Cognitive Level: Application

Integrated Process: Implementation

16. Which of the following characteristics of accurately developed client outcomes should a nurse identify? (Select all that apply.)

1. Client outcomes are specifically formulated by nurses.

2. Client outcomes are not restricted by time frames.

3. Client outcomes are specific and measurable.

4. Client outcomes are realistically based on client capability.

5. Client outcomes are formally approved by the psychiatrist.

ANS: 3, 4

Rationale: The nurse should identify that client outcomes should be specific, measurable, and realistically based on client capability. Outcomes should be derived from the diagnosis and should include a time estimate for attainment. Outcomes are most effective when formulated cooperatively by the interdisciplinary team members, the client, and significant others.

Cognitive Level: Application

Integrated Process: Planning

Ordered Response

17. Number the following nursing interventions as they would proceed through the steps of the nursing process.

________ Determine if an antianxiety medication is decreasing a clients stress.

________ Measure a clients vital signs and review past history.

________ Encourage deep breathing and teach relaxation techniques.

________ Aim, with client collaboration, for a seven-hour nights sleep.

________ Recognize and document the clients problem.

ANS: The correct order is 5, 1, 4, 3, 2

Rationale:

1. Measuring a clients vital signs and reviewing past history is a nursing intervention that occurs in the assessment step of the nursing process.

2. Recognizing and documenting the clients problem occurs in the nursing diagnosis step.

3. Setting a goal with client collaboration, for a seven-hour nights sleep occurs in the planning step.

4. Encouraging deep breathing and teaching relaxation techniques occur in the implementation step.

5. Determining if an antianxiety medication is decreasing a clients stress occurs in the evaluation step.

Cognitive Level: Analysis

Integrated Process: Implementation

Fill-in-the-Blank

18. A _________________ __________________ provides the basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability.

ANS: nursing diagnosis

Rationale: Nursing diagnoses are clinical judgments about individual, family, or community experiences/responses to actual or potential health problems/life processes. A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability.