Psychotherapy for theAdvanced Practice Psychiatric Nurse, Second Edition:AHow-To Guide for EvidenceBased Practice 2nd Edition Test Bank

Chapter 1. The Nurse Psychotherapist and a Framework for Practice

Question 1

The nurses new job description at the generalist level of practice reflects the definition of psychiatricmental health nursing and the PsychiatricMental Health Nursing Standards of Practice (ANA, APNA, ISPN). In which of the following areas might the nurse plan programs and intervention to fulfill employment expectations?

Standard Text: Select all that apply.

1. Stress management strategies

2. Early diagnosis of psychiatric disorders

3. Parenting classes for new parents

4. Family and group psychotherapy

5. Medication teaching for anti-anxiety medications

Correct Answer: 1,3,4,5

Rationale 1: Stress management strategies address health, wellness, and care of mental health problems and are appropriate for psychiatricmental health nursing at the generalist level of practice.

Rationale 2: Early diagnosis of psychiatric disorders is generally not consistent with the definition or practice of psychiatricmental health nursing especially at the generalist level.

Rationale 3: Parenting classes for new parents provide teaching that is consistent with the prevention of mental health problems and is consistent with psychiatricmental health nursing at the generalist level of practice.

Rationale 4: Family and group psychotherapy is consistent at the advanced practice registered nurse level but not the generalist level.

Rationale 5: Medication teaching for anti-anxiety medications promotes quality of care for persons with psychiatric disorders and is vital for psychiatricmental health nursing practice at the generalist level of practice.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: Apply knowledge of current practice and professional performance standards to the delivery of contemporary psychiatricmental health nursing.

Question 2

Type: MCSA

The nurse is serving on a committee charged with reviewing the roles and responsibilities of the nurses on the psychiatric unit. Which publication should the nurse bring to the first meeting?

1. Diagnostic and Statistical Manual of Mental Disorders

2. American Nurses Credentialing Center certification requirements

3. American Nurses Association, Code of Ethics

4. PsychiatricMental Health Nursing Standards of Practice

Correct Answer: 4

Rationale 1: The PsychiatricMental Health Nursing Standards of Practice delineates psychiatricmental health nursing roles and functions and serves as guidelines for providing quality care. The Diagnostic and Statistical Manual of Mental Disorders is used by the mental health care team, particularly the psychiatrist, to diagnose clients with mental disorders and is not specific to nursing care issues. The Code of Ethics helps to clarify right and wrong actions by the nurse, but does not clarify roles and nursing care actions. Certification requirements outline steps toward certification that acknowledge knowledge and expertise, but do not delineate roles and responsibilities.

Rationale 2: The PsychiatricMental Health Nursing Standards of Practice delineates psychiatricmental health nursing roles and functions and serves as guidelines for providing quality care. The Diagnostic and Statistical Manual of Mental Disorders is used by the mental health care team, particularly the psychiatrist, to diagnose clients with mental disorders and is not specific to nursing care issues. The Code of Ethics helps to clarify right and wrong actions by the nurse, but does not clarify roles and nursing care actions. Certification requirements outline steps toward certification that acknowledge knowledge and expertise, but do not delineate roles and responsibilities.

Rationale 3: The PsychiatricMental Health Nursing Standards of Practice delineates psychiatricmental health nursing roles and functions and serves as guidelines for providing quality care. The Diagnostic and Statistical Manual of Mental Disorders is used by the mental health care team, particularly the psychiatrist, to diagnose clients with mental disorders and is not specific to nursing care issues. The Code of Ethics helps to clarify right and wrong actions by the nurse, but does not clarify roles and nursing care actions. Certification requirements outline steps toward certification that acknowledge knowledge and expertise, but do not delineate roles and responsibilities.

Rationale 4: The PsychiatricMental Health Nursing Standards of Practice delineates psychiatricmental health nursing roles and functions and serves as guidelines for providing quality care. The Diagnostic and Statistical Manual of Mental Disorders is used by the mental health care team, particularly the psychiatrist, to diagnose clients with mental disorders and is not specific to nursing care issues. The Code of Ethics helps to clarify right and wrong actions by the nurse, but does not clarify roles and nursing care actions. Certification requirements outline steps toward certification that acknowledge knowledge and expertise, but do not delineate roles and responsibilities.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: Apply knowledge of current practice and professional performance standards to the delivery of contemporary psychiatricmental health nursing.

Question 3

Type: MCSA

The psychiatricmental health nurse reflecting on professional role activities is referred to the standards of professional performance by a colleague. To which organization should the nurse look for guidance?

1. North American Nursing Diagnosis Association

2. American Nurses Credentialing Center

3. National League for Nursing

4. American Nurses Association

Correct Answer: 4

Rationale 1: The American Nurses Association will be the best resource as professional performance is addressed in standards 715 of ANAs PsychiatricMental Health Nursing Standards of Practice. The National League for Nursing primarily addresses nursing education, while the American Nurses Association

Credentialing Center focuses on certification. The North American Nursing Diagnosis Association develops a classification system for nursing diagnoses.

Rationale 2: The American Nurses Association will be the best resource as professional performance is addressed in standards 715 of ANAs PsychiatricMental Health Nursing Standards of Practice. The National League for Nursing primarily addresses nursing education, while the American Nurses Association

Credentialing Center focuses on certification. The North American Nursing Diagnosis Association develops a classification system for nursing diagnoses.

Rationale 3: The American Nurses Association will be the best resource as professional performance is addressed in standards 715 of ANAs PsychiatricMental Health Nursing Standards of Practice. The National League for Nursing primarily addresses nursing education, while the American Nurses Association

Credentialing Center focuses on certification. The North American Nursing Diagnosis Association develops a classification system for nursing diagnoses.

Rationale 4: The American Nurses Association will be the best resource as professional performance is addressed in standards 715 of ANAs PsychiatricMental Health Nursing Standards of Practice. The National League for Nursing primarily addresses nursing education, while the American Nurses Association

Credentialing Center focuses on certification. The North American Nursing Diagnosis Association develops a classification system for nursing diagnoses.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: Apply knowledge of current practice and professional performance standards to the delivery of contemporary psychiatricmental health nursing.

Question 4

Type: MCSA

The psychiatricmental health nurse is working with the new graduate nurse who is orienting to the psychiatric unit. Which comment by the new graduate indicates further clarification of the generalist-nursing role is needed?

1. I would feel better if you would look at my documentation that addresses progress toward treatment goals.

2. I will spend time each day evaluating the effectiveness of the therapeutic milieu.

3. I am a little nervous about conducting psychotherapy with clients.

4. I am doing some reading on how to incorporate complementary interventions into treatment plans.

Correct Answer: 3

Rationale 1: The intent to conduct psychotherapy with clients is not consistent with the role of the nurse at the generalist level of practice as outlined in the PsychiatricMental Health Nursing Standards of Practice and indicates a need for role clarification. Evaluation of the therapeutic milieu, documenting progress toward treatment goals, and incorporating complementary interventions are consistent with the roles of the psychiatricmental health nurse practicing at the generalist level.

Rationale 2: The intent to conduct psychotherapy with clients is not consistent with the role of the nurse at the generalist level of practice as outlined in the PsychiatricMental Health Nursing Standards of Practice and indicates a need for role clarification. Evaluation of the therapeutic milieu, documenting progress toward treatment goals, and incorporating complementary interventions are consistent with the roles of the psychiatricmental health nurse practicing at the generalist level.

Rationale 3: The intent to conduct psychotherapy with clients is not consistent with the role of the nurse at the generalist level of practice as outlined in the PsychiatricMental Health Nursing Standards of Practice and indicates a need for role clarification. Evaluation of the therapeutic milieu, documenting progress toward treatment goals, and incorporating complementary interventions are consistent with the roles of the psychiatricmental health nurse practicing at the generalist level.

Rationale 4: The intent to conduct psychotherapy with clients is not consistent with the role of the nurse at the generalist level of practice as outlined in the PsychiatricMental Health Nursing Standards of Practice and indicates a need for role clarification. Evaluation of the therapeutic milieu, documenting progress toward treatment goals, and incorporating complementary interventions are consistent with the roles of the psychiatricmental health nurse practicing at the generalist level.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: Apply knowledge of current practice and professional performance standards to the delivery of contemporary psychiatricmental health nursing.

Question 5

Type: MCSA

The client on the psychiatric unit is asking questions about prevention of sexually transmitted diseases. Given the PsychiatricMental Health Nursing Standards of Practice, which action would be most appropriate for the nurse to take at this time?

1. Consult with the mental health care team.

2. Teach safer sexual practices.

3. Investigate the questions in individual psychotherapy.

4. Notify the attending psychiatrist.

Rationale 1: The psychiatricmental health nurse employs strategies to promote health and a safe environment and teaches safer sexual practices to the client who is asking for the information. Notifying the psychiatrist and consulting with the mental health care team is not necessary as health teaching is within the independent practice of the RN. Conducting individual psychotherapy is not within the practice standards for the generalist nurse.

Rationale 2: The psychiatricmental health nurse employs strategies to promote health and a safe environment and teaches safer sexual practices to the client who is asking for the information. Notifying the psychiatrist and consulting with the mental health care team is not necessary as health teaching is within the independent practice of the RN. Conducting individual psychotherapy is not within the practice standards for the generalist nurse.

Rationale 3: The psychiatricmental health nurse employs strategies to promote health and a safe environment and teaches safer sexual practices to the client who is asking for the information. Notifying the psychiatrist and consulting with the mental health care team is not necessary as health teaching is within the independent practice of the RN. Conducting individual psychotherapy is not within the practice standards for the generalist nurse.

Rationale 4: The psychiatricmental health nurse employs strategies to promote health and a safe environment and teaches safer sexual practices to the client who is asking for the information. Notifying the psychiatrist and consulting with the mental health care team is not necessary as health teaching is within the independent practice of the RN. Conducting individual psychotherapy is not within the practice standards for the generalist nurse.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Apply knowledge of current practice and professional performance standards to the delivery of contemporary psychiatricmental health nursing.

Question 6

Type: MCSA

The client asks the nurse if certain changes can be made in the unit milieu. Which action by the nurse indicates understanding of the nursing role in the therapeutic milieu?

1. The nurse refers the clients requests to the psychiatric social worker.

2. The nurse discusses the desired changes with the client.

3. The nurse refers the clients requests to the psychosocial rehabilitation worker.

4. The nurse instructs the client that no changes can be made.

Correct Answer: 2

Rationale 1: The psychiatricmental health nurse has major responsibility for the milieu; therefore, it is appropriate to discuss requested changes in order to gather information regarding the effectiveness of the milieu. The psychiatric social worker identifies community resources and may perform counseling. It is nontherapeutic to instruct the client that no changes can be made before gathering data in relation to the clients requests. The psychosocial rehabilitation worker teaches day-to-day skills for living and may provide case management services.

Rationale 2: The psychiatricmental health nurse has major responsibility for the milieu; therefore, it is appropriate to discuss requested changes in order to gather information regarding the effectiveness of the milieu. The psychiatric social worker identifies community resources and may perform counseling. It is nontherapeutic to instruct the client that no changes can be made before gathering data in relation to the clients requests. The psychosocial rehabilitation worker teaches day-to-day skills for living and may provide case management services.

Rationale 3: The psychiatricmental health nurse has major responsibility for the milieu; therefore, it is appropriate to discuss requested changes in order to gather information regarding the effectiveness of the milieu. The psychiatric social worker identifies community resources and may perform counseling. It is nontherapeutic to instruct the client that no changes can be made before gathering data in relation to the clients requests. The psychosocial rehabilitation worker teaches day-to-day skills for living and may provide case management services.

Rationale 4: The psychiatricmental health nurse has major responsibility for the milieu; therefore, it is appropriate to discuss requested changes in order to gather information regarding the effectiveness of the milieu. The psychiatric social worker identifies community resources and may perform counseling. It is non- therapeutic to instruct the client that no changes can be made before gathering data in relation to the clients requests. The psychosocial rehabilitation worker teaches day-to-day skills for living and may provide case management services.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: Compare and contrast the differences and similarities among the roles of the psychiatricmental health nurse and other members of the mental health team.

Question 7

Type: MCSA

The nurse assesses that the mental health client has problems choosing productive, safe leisure activities. Which member of the mental health team should the nurse consult with?

Correct Answer: 1

Rationale 1: The recreational therapist plans and guides recreational activities to provide socialization, healthful recreation, and desirable interpersonal and intrapsychic experiences and will be the member of the healthcare team to take the lead in the implementation of this portion of the treatment plan. While all members of the team work together, the psychiatrist is responsible for the diagnosis and treatment of the mental illness. The occupational therapist teaches self-help activities and helps prepare the client for employment. The clinical psychologists foci are psychotherapy, behavior modification, and psychological testing.

Rationale 2: The recreational therapist plans and guides recreational activities to provide socialization, healthful recreation, and desirable interpersonal and intrapsychic experiences and will be the member of the healthcare team to take the lead in the implementation of this portion of the treatment plan. While all members of the team work together, the psychiatrist is responsible for the diagnosis and treatment of the mental illness. The occupational therapist teaches self-help activities and helps prepare the client for employment. The clinical psychologists foci are psychotherapy, behavior modification, and psychological testing.

Rationale 3: The recreational therapist plans and guides recreational activities to provide socialization, healthful recreation, and desirable interpersonal and intrapsychic experiences and will be the member of the healthcare team to take the lead in the implementation of this portion of the treatment plan. While all members of the team work together, the psychiatrist is responsible for the diagnosis and treatment of the mental illness. The occupational therapist teaches self-help activities and helps prepare the client for employment. The clinical psychologists foci are psychotherapy, behavior modification, and psychological testing.

Rationale 4: The recreational therapist plans and guides recreational activities to provide socialization, healthful recreation, and desirable interpersonal and intrapsychic experiences and will be the member of the healthcare team to take the lead in the implementation of this portion of the treatment plan. While all members of the team work together, the psychiatrist is responsible for the diagnosis and treatment of the mental illness. The occupational therapist teaches self-help activities and helps prepare the client for employment. The clinical psychologists foci are psychotherapy, behavior modification, and psychological testing.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Compare and contrast the differences and similarities among the roles of the psychiatricmental health nurse and other members of the mental health team.

Question 8

Type: MCSA

Upon arrival on the psychiatric unit this morning, which activity should be the nurses focus? The nurse should do which of the following?

1. Review psychological testing results for all clients.

2. Schedule the individual therapy sessions for all clients.

3. Identify community resources for clients to be discharged this morning.

4. Assess each client for whom the nurse will be providing care.

Correct Answer: 4

Rationale 1: The nurse is responsible for implementing the nursing process and nursing care for clients. The psychiatric social worker has major responsibility for the identification of post-discharge community resources. The clinical psychologists primary foci are psychotherapy and psychological testing.

Rationale 2: The nurse is responsible for implementing the nursing process and nursing care for clients. The psychiatric social worker has major responsibility for the identification of post-discharge community resources. The clinical psychologists primary foci are psychotherapy and psychological testing.

Rationale 3: The nurse is responsible for implementing the nursing process and nursing care for clients. The psychiatric social worker has major responsibility for the identification of post-discharge community resources. The clinical psychologists primary foci are psychotherapy and psychological testing.

Rationale 4: The nurse is responsible for implementing the nursing process and nursing care for clients. The psychiatric social worker has major responsibility for the identification of post-discharge community resources. The clinical psychologists primary foci are psychotherapy and psychological testing.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: Compare and contrast the differences and similarities among the roles of the psychiatricmental health nurse and other members of the mental health team.

Question 9

Type: MCSA

Due to a staff members absence, the nurse is reviewing staff assignments for the day. Which task can the nurse delegate to the psychosocial rehabilitation worker?

1. Conflict resolution teaching to a small group of clients

2. Comparison of physicians orders with the medication records

3. Routine medication administration to a stable client

4. Assessment of a long-term client

Correct Answer: 1

Rationale 1: The psychiatric rehabilitation worker teaches clients practical, day-to-day skills for living in the community, which might include conflict resolution. Medication administration, comparison of physician orders with medication records, and assessment fall within the nursing role and cannot be delegated.

Rationale 2: The psychiatric rehabilitation worker teaches clients practical, day-to-day skills for living in the community, which might include conflict resolution. Medication administration, comparison of physician orders with medication records, and assessment fall within the nursing role and cannot be delegated.

Rationale 3: The psychiatric rehabilitation worker teaches clients practical, day-to-day skills for living in the community, which might include conflict resolution. Medication administration, comparison of physician orders with medication records, and assessment fall within the nursing role and cannot be delegated.

Rationale 4: The psychiatric rehabilitation worker teaches clients practical, day-to-day skills for living in the community, which might include conflict resolution. Medication administration, comparison of physician orders with medication records, and assessment fall within the nursing role and cannot be delegated.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Compare and contrast the differences and similarities among the roles of the psychiatricmental health nurse and other members of the mental health team.

Question 10

Type: MCSA

The clients treatment plan includes teaching related to possible side effects of psychotropic medications. Which member of the mental health team should plan to implement the teaching?

1. The psychosocial rehabilitation worker

2. The primary therapist

3. The psychiatrist

4. The nurse

Correct Answer: 4

Rationale 1: The nurse is responsible for the nursing care of the client including medication administration and teaching. While the psychiatrist may also do some teaching, he/she is primarily responsible for the diagnosis and medication prescription. The primary therapist is most likely a clinical psychologist or psychiatric social worker who would not have the educational preparation or license consistent with medication teaching. The psychosocial rehabilitation worker is an unlicensed member of the team and would not have the role of medication teaching.

Rationale 2: The nurse is responsible for the nursing care of the client including medication administration and teaching. While the psychiatrist may also do some teaching, he/she is primarily responsible for the diagnosis and medication prescription. The primary therapist is most likely a clinical psychologist or psychiatric social worker who would not have the educational preparation or license consistent with medication teaching. The psychosocial rehabilitation worker is an unlicensed member of the team and would not have the role of medication teaching.

Rationale 3: The nurse is responsible for the nursing care of the client including medication administration and teaching. While the psychiatrist may also do some teaching, he/she is primarily responsible for the diagnosis and medication prescription. The primary therapist is most likely a clinical psychologist or psychiatric social worker who would not have the educational preparation or license consistent with medication teaching. The psychosocial rehabilitation worker is an unlicensed member of the team and would not have the role of medication teaching.

Rationale 4: The nurse is responsible for the nursing care of the client including medication administration and teaching. While the psychiatrist may also do some teaching, he/she is primarily responsible for the diagnosis and medication prescription. The primary therapist is most likely a clinical psychologist or psychiatric social worker who would not have the educational preparation or license consistent with medication teaching. The psychosocial rehabilitation worker is an unlicensed member of the team and would not have the role of medication teaching.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: Compare and contrast the differences and similarities among the roles of the psychiatricmental health nurse and other members of the mental health team.

Question 11

Type: MCSA

The mental health team nurse is having some role issues regarding how best to facilitate client progress toward therapeutic goals. What is the priority action by the nurse in order to aid the team as they assist the client?

1. Acknowledge the diversity of the mental health team.

2. Recognize that conflict is natural and expected.

3. Determine personal values, biases, and goals.

4. Attend all mental health team meetings.

Correct Answer: 3

Rationale 1: The priority nursing action is to determine personal values, biases, and goals; these, especially if out of the awareness of the nurse, may be a factor in team dynamics. Acknowledging the diversity of the team, recognizing that conflict is natural, and attending all mental health team meetings are appropriate actions, but not the priority.

Rationale 2: The priority nursing action is to determine personal values, biases, and goals; these, especially if out of the awareness of the nurse, may be a factor in team dynamics. Acknowledging the diversity of the team, recognizing that conflict is natural, and attending all mental health team meetings are appropriate actions, but not the priority.

Rationale 3: The priority nursing action is to determine personal values, biases, and goals; these, especially if out of the awareness of the nurse, may be a factor in team dynamics. Acknowledging the diversity of the team, recognizing that conflict is natural, and attending all mental health team meetings are appropriate actions, but not the priority.

Rationale 4: The priority nursing action is to determine personal values, biases, and goals; these, especially if out of the awareness of the nurse, may be a factor in team dynamics. Acknowledging the diversity of the team, recognizing that conflict is natural, and attending all mental health team meetings are appropriate actions, but not the priority.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Analyze the factors that influence the success with which the mental health team achieves collaboration among its members and with clients and their significant others.

Question 12

Type: MCSA

The nurse reflecting on the nursing role within the mental health team, understands that the main purpose of delivering care using a multidisciplinary team is to do which of the following?

1. Maximize the efficiency of the health care team with each team member learning from the others.

2. Increase the opportunity for interpersonal interaction among the client, family, and team members.

3. Facilitate the case management process by delivering care using a multidisciplinary health care team.

4. Make the best use of the different abilities of mental health team members in order to facilitate client progress.

Correct Answer: 4

Rationale 1: The purpose of partnering and collaborating with other disciplines is to make the best use of the different abilities of mental health team members in order to facilitate client progress toward therapeutic goals. While client-centered interpersonal interaction within a therapeutic relationship is a vital piece of the treatment plan, interpersonal interaction unto itself may not be the needed focus. Facilitating the case management process and maximizing efficiency of the health care team are not primary purposes of a team approach. All care must be focused on the clients and their needs.

Rationale 2: The purpose of partnering and collaborating with other disciplines is to make the best use of the different abilities of mental health team members in order to facilitate client progress toward therapeutic goals. While client-centered interpersonal interaction within a therapeutic relationship is a vital piece of the treatment plan, interpersonal interaction unto itself may not be the needed focus. Facilitating the case management process and maximizing efficiency of the health care team are not primary purposes of a team approach. All care must be focused on the clients and their needs.

Rationale 3: The purpose of partnering and collaborating with other disciplines is to make the best use of the different abilities of mental health team members in order to facilitate client progress toward therapeutic goals. While client-centered interpersonal interaction within a therapeutic relationship is a vital piece of the treatment plan, interpersonal interaction unto itself may not be the needed focus. Facilitating the case management process and maximizing efficiency of the health care team are not primary purposes of a team approach. All care must be focused on the clients and their needs.

Rationale 4: The purpose of partnering and collaborating with other disciplines is to make the best use of the different abilities of mental health team members in order to facilitate client progress toward therapeutic goals. While client-centered interpersonal interaction within a therapeutic relationship is a vital piece of the treatment plan, interpersonal interaction unto itself may not be the needed focus. Facilitating the case management process and maximizing efficiency of the health care team are not primary purposes of a team approach. All care must be focused on the clients and their needs.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: Analyze the factors that influence the success with which the mental health team achieves collaboration among its members and with clients and their significant others.

Question 13

Type: MCSA

Observation of the behavior of the mental health team seems to indicate that one team member is primarily interested in client progress as a measure of their knowledge and expertise. Given the nurses knowledge of game theories, this team member might be functioning as which of the following?

2. Leader

3. Enabler

4. Maximizer

Correct Answer: 4

Rationale 1: The maximizer is one who is primarily interested only in his or her own gain. A rivalist would be a person whose primary interest is defeating other team members. An enabler is one who facilitates the continuation of what are usually inappropriate behaviors in others and usually not associated with game theory. A leader would function more in the role of a cooperator, one who is interested in helping both themselves and their partners.

Rationale 2: The maximizer is one who is primarily interested only in his or her own gain. A rivalist would be a person whose primary interest is defeating other team members. An enabler is one who facilitates the continuation of what are usually inappropriate behaviors in others and usually not associated with game theory. A leader would function more in the role of a cooperator, one who is interested in helping both themselves and their partners.

Rationale 3: The maximizer is one who is primarily interested only in his or her own gain. A rivalist would be a person whose primary interest is defeating other team members. An enabler is one who facilitates the continuation of what are usually inappropriate behaviors in others and usually not associated with game theory.

A leader would function more in the role of a cooperator, one who is interested in helping both themselves and their partners.

Rationale 4: The maximizer is one who is primarily interested only in his or her own gain. A rivalist would be a person whose primary interest is defeating other team members. An enabler is one who facilitates the continuation of what are usually inappropriate behaviors in others and usually not associated with game theory. A leader would function more in the role of a cooperator, one who is interested in helping both themselves and their partners.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: Analyze the factors that influence the success with which the mental health team achieves collaboration among its members and with clients and their significant others.

Question 14

Type: MCMA

The nurse is planning activities to enhance collaboration within the mental health care team. Which activities will be helpful toward this goal?

Standard Text: Select all that apply.

1. Identification of ways to minimize diversity among team members

2. Discussion of decisions that require team unity

3. Identification of ways to ignore individual power bases

4. Review of interpersonal communication skills

5. Discussion of decisions that can be made autonomously

Correct Answer: 2,5

Rationale 1: Identification of ways to minimize diversity among team members. Effective collaboration on a team involves the ability to value diversity and turn differences into assets. An inability to value diversity may be a detriment to the teams efforts.

Rationale 2: Discussion of decisions that require team unity. Unity should be balanced with autonomy. Identification of parameters for nursing collaboration would be useful toward the goal.

Rationale 3: Identification of ways to ignore individual power bases. Team members should recognize rather than ignore personal power bases and share power with others. Ignoring this element may decrease the effectiveness of collaboration.

Rationale 4: Review of interpersonal communication skills Effective communication and processing skills will enhance effective collaboration.

Rationale 5: Discussion of decisions that can be made autonomously. Unity should be balanced with autonomy. Collaboration is not required for all decisions.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: Analyze the factors that influence the success with which the mental health team achieves collaboration among its members and with clients and their significant others.

Question 15

Type: MCSA

The nurse is admitting a client to the psychiatric unit. Which nursing action is correct?

1. Instruct the client that all information gathered during the assessment will be shared with the mental health team.

2. Alert the client that the psychiatrist will do all the intake assessment to maximize the efficiency of the team.

3. Discuss with the client information that is to be shared with family members and the mental health team.

4. Instruct the client that the mental health team will decide what the client needs to do in treatment.

Correct Answer: 3

Rationale 1: Discussing with the client information that is to be shared with family members and the mental health team is an action that promotes a partnership with the client and enhances effectiveness of treatment. The nurse should communicate to the client that decisions related to the sharing of information would take into consideration any agreement regarding disclosure that exists between the nurse and the client and how the receiving party will use the information in the clients best interest. Not all information is significant to the clients reason for treatment. The nurse should communicate circumstances where significant information will be shared. In the spirit of collaboration, the mental health team should involve the client. This assures that clients are informed consumers of mental health services. While the psychiatrist will assess the client from the medical perspective, the nurse must assess the clients responses to the mental disorder in order to plan appropriate nursing care.

Rationale 2: Discussing with the client information that is to be shared with family members and the mental health team is an action that promotes a partnership with the client and enhances effectiveness of treatment. The nurse should communicate to the client that decisions related to the sharing of information would take into consideration any agreement regarding disclosure that exists between the nurse and the client and how the receiving party will use the information in the clients best interest. Not all information is significant to the clients reason for treatment. The nurse should communicate circumstances where significant information will be shared. In the spirit of collaboration, the mental health team should involve the client. This assures that clients are informed consumers of mental health services. While the psychiatrist will assess the client from the medical perspective, the nurse must assess the clients responses to the mental disorder in order to plan appropriate nursing care.

Rationale 3: Discussing with the client information that is to be shared with family members and the mental health team is an action that promotes a partnership with the client and enhances effectiveness of treatment. The nurse should communicate to the client that decisions related to the sharing of information would take into consideration any agreement regarding disclosure that exists between the nurse and the client and how the receiving party will use the information in the clients best interest. Not all information is significant to the clients reason for treatment. The nurse should communicate circumstances where significant information will be shared. In the spirit of collaboration, the mental health team should involve the client. This assures that clients are informed consumers of mental health services. While the psychiatrist will assess the client from the medical perspective, the nurse must assess the clients responses to the mental disorder in order to plan appropriate nursing care.

Rationale 4: Discussing with the client information that is to be shared with family members and the mental health team is an action that promotes a partnership with the client and enhances effectiveness of treatment. The nurse should communicate to the client that decisions related to the sharing of information would take into consideration any agreement regarding disclosure that exists between the nurse and the client and how the receiving party will use the information in the clients best interest. Not all information is significant to the clients reason for treatment. The nurse should communicate circumstances where significant information will be shared. In the spirit of collaboration, the mental health team should involve the client. This assures that clients are informed consumers of mental health services. While the psychiatrist will assess the client from the medical perspective, the nurse must assess the clients responses to the mental disorder in order to plan appropriate nursing care.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Analyze the factors that influence the success with which the mental health team achieves collaboration among its members and with clients and their significant others.

Question 16

Type: MCSA

The correct response of the nurse who is asked if Florence Nightingale had any impact on the role of the nurse in psychiatricmental health nursing should be which of the following?

1. No, Nightingale focused her ideas on nursing education rather than direct client care.

2. Yes, Nightingale was among the first to note that the influence of nurses has psychological components.

3. No, Nightingale emphasized the physical environment for healing.

4. Yes, Nightingale developed the idea of the therapeutic relationship.

Rationale 1: Although it is true that in the context of her time Nightingale emphasized the physical environment, she did have an impact on psychiatricmental health nursing. Nightingale was among the first to note that the influence of nurses on their clients goes beyond physical care and has psychological and social components; hence, the value of making her famous evening rounds to say goodnight. Nightingale focused her ideas on both direct client care and nursing education. Hildegard Peplau is credited with theory related to the therapeutic nurseclient relationship.

Rationale 2: Although it is true that in the context of her time Nightingale emphasized the physical environment, she did have an impact on psychiatricmental health nursing. Nightingale was among the first to note that the influence of nurses on their clients goes beyond physical care and has psychological and social components; hence, the value of making her famous evening rounds to say goodnight. Nightingale focused her ideas on both direct client care and nursing education. Hildegard Peplau is credited with theory related to the therapeutic nurseclient relationship.

Rationale 3: Although it is true that in the context of her time Nightingale emphasized the physical environment, she did have an impact on psychiatricmental health nursing. Nightingale was among the first to note that the influence of nurses on their clients goes beyond physical care and has psychological and social components; hence, the value of making her famous evening rounds to say goodnight. Nightingale focused her ideas on both direct client care and nursing education. Hildegard Peplau is credited with theory related to the therapeutic nurseclient relationship.

Rationale 4: Although it is true that in the context of her time Nightingale emphasized the physical environment, she did have an impact on psychiatricmental health nursing. Nightingale was among the first to note that the influence of nurses on their clients goes beyond physical care and has psychological and social components; hence, the value of making her famous evening rounds to say goodnight. Nightingale focused her ideas on both direct client care and nursing education. Hildegard Peplau is credited with theory related to the therapeutic nurseclient relationship.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Describe how the role of the psychiatricmental health nurse changed over the years from that of custodian to a multifaceted role.

Question 17

Type: MCSA

The nurse planning a brief presentation about the first American psychiatric nurse will research which of the following?

1. Hildegard Peplau

2. Harriet Bailey

3. Linda Richards

4. Gwen Tudor (Will)

Correct Answer: 3

Rationale 1: Linda Richards, the first American psychiatric nurse, opened the first American school for psychiatric nurses and spent a significant part of her career developing better nursing care in psychiatric hospitals. Hildegard Peplau developed the first systematic theoretic framework in psychiatric nursing. Harriet Bailey wrote the first psychiatric nursing text, Nursing Mental Diseases. Gwen Tudor (Will) was the first nurse to publish an article in the journal Psychiatry. While the last three nurses made significant contributions, the title of first American psychiatric nurse, falls to Linda Richards.

Rationale 2: Linda Richards, the first American psychiatric nurse, opened the first American school for psychiatric nurses and spent a significant part of her career developing better nursing care in psychiatric hospitals. Hildegard Peplau developed the first systematic theoretic framework in psychiatric nursing. Harriet Bailey wrote the first psychiatric nursing text, Nursing Mental Diseases. Gwen Tudor (Will) was the first nurse to publish an article in the journal Psychiatry. While the last three nurses made significant contributions, the title of first American psychiatric nurse, falls to Linda Richards.

Rationale 3: Linda Richards, the first American psychiatric nurse, opened the first American school for psychiatric nurses and spent a significant part of her career developing better nursing care in psychiatric hospitals. Hildegard Peplau developed the first systematic theoretic framework in psychiatric nursing. Harriet Bailey wrote the first psychiatric nursing text, Nursing Mental Diseases. Gwen Tudor (Will) was the first nurse to publish an article in the journal Psychiatry. While the last three nurses made significant contributions, the title of first American psychiatric nurse, falls to Linda Richards.

Rationale 4: Linda Richards, the first American psychiatric nurse, opened the first American school for psychiatric nurses and spent a significant part of her career developing better nursing care in psychiatric hospitals. Hildegard Peplau developed the first systematic theoretic framework in psychiatric nursing. Harriet Bailey wrote the first psychiatric nursing text, Nursing Mental Diseases. Gwen Tudor (Will) was the first nurse to publish an article in the journal Psychiatry. While the last three nurses made significant contributions, the title of first American psychiatric nurse, falls to Linda Richards.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: Describe how the role of the psychiatricmental health nurse changed over the years from that of custodian to a multifaceted role.

Question 18

Type: MCSA

The nurse is reflecting on psychiatric nursing care in the 19th century. Which nursing diagnosis is most consistent with the focus of psychiatric nursing care during the 19th century?

1. Ineffective individual coping

2. Self-care deficit

3. Anxiety

4. Altered thought processes

Correct Answer: 2

Rationale 1: During the 19th century, psychiatric nurses attended mainly to the physical needs of clients and did not pursue systematic interpersonal work with them. Psychiatric nursing practice was primarily custodial. Nursing care that systematically addresses anxiety, coping, and altered-thought processes did not come about until the mid 20th century.

Rationale 2: During the 19th century, psychiatric nurses attended mainly to the physical needs of clients and did not pursue systematic interpersonal work with them. Psychiatric nursing practice was primarily custodial. Nursing care that systematically addresses anxiety, coping, and altered-thought processes did not come about until the mid 20th century.

Rationale 3: During the 19th century, psychiatric nurses attended mainly to the physical needs of clients and did not pursue systematic interpersonal work with them. Psychiatric nursing practice was primarily custodial. Nursing care that systematically addresses anxiety, coping, and altered-thought processes did not come about until the mid 20th century.

Rationale 4: During the 19th century, psychiatric nurses attended mainly to the physical needs of clients and did not pursue systematic interpersonal work with them. Psychiatric nursing practice was primarily custodial. Nursing care that systematically addresses anxiety, coping, and altered-thought processes did not come about until the mid 20th century.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: Describe how the role of the psychiatricmental health nurse changed over the years from that of custodian to a multifaceted role.

Question 19

Type: MCSA

On which dimension would the nurse most likely focus data collection if the nurse was assessing the client from primarily a 19th century perspective?

Correct Answer: 2

Rationale 1: Up until the early to mid-20th century, psychiatric nurses attended primarily to the physical needs of the clients and did not pursue interpersonal work with them. Psychiatric nursing care during this period emphasized a physical environment that would promote recovery. More holistic care (including emotionalsocial-spiritual dimensions) is a product of more recent history.

Rationale 2: Up until the early to mid-20th century, psychiatric nurses attended primarily to the physical needs of the clients and did not pursue interpersonal work with them. Psychiatric nursing care during this period emphasized a physical environment that would promote recovery. More holistic care (including emotionalsocial-spiritual dimensions) is a product of more recent history.

Rationale 3: Up until the early to mid-20th century, psychiatric nurses attended primarily to the physical needs of the clients and did not pursue interpersonal work with them. Psychiatric nursing care during this period emphasized a physical environment that would promote recovery. More holistic care (including emotionalsocial-spiritual dimensions) is a product of more recent history.

Rationale 4: Up until the early to mid-20th century, psychiatric nurses attended primarily to the physical needs of the clients and did not pursue interpersonal work with them. Psychiatric nursing care during this period emphasized a physical environment that would promote recovery. More holistic care (including emotionalsocial-spiritual dimensions) is a product of more recent history.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Describe how the role of the psychiatricmental health nurse changed over the years from that of custodian to a multifaceted role.

Question 20

Type: MCSA

The nursing student is asked which historical event was most significant in the development of psychiatric nursing as a specialty and psychotherapeutic roles for nurses. Which response by the nursing student indicates understanding of important events related to development of the psychiatric nursing role?

1. Release of the report Nursing for the Future

2. Passage of the Community Mental Health Centers Act

3. Publication of Commonsense Psychiatry

4. Passage of the National Mental Health Act

Correct Answer: 4

Rationale 1: The National Mental Health Act of 1946 is probably the most significant piece of legislation affecting the development of psychiatricmental health nursing. Within this act, psychiatric nursing was added to psychiatry, psychology, and social work as a field in which the highest priority became the preparation of clinically capable persons for positions of leadership. Commonsense Psychiatry, written by Adolf Meyer, had great impact on psychiatry; however, it did not have a noticeable influence on psychiatric nursing. Nursing for the Future eliminated single-focus schools of psychiatric nursing. The Community Mental Health Centers Act of 1963 encouraged the closing of large mental hospitals and further encouraged the trend toward expanded nursing roles at the graduate level.

Rationale 2: The National Mental Health Act of 1946 is probably the most significant piece of legislation affecting the development of psychiatricmental health nursing. Within this act, psychiatric nursing was added to psychiatry, psychology, and social work as a field in which the highest priority became the preparation of clinically capable persons for positions of leadership. Commonsense Psychiatry, written by Adolf Meyer, had great impact on psychiatry; however, it did not have a noticeable influence on psychiatric nursing. Nursing for the Future eliminated single-focus schools of psychiatric nursing. The Community Mental Health Centers Act of 1963 encouraged the closing of large mental hospitals and further encouraged the trend toward expanded nursing roles at the graduate level.

Rationale 3: The National Mental Health Act of 1946 is probably the most significant piece of legislation affecting the development of psychiatricmental health nursing. Within this act, psychiatric nursing was added to psychiatry, psychology, and social work as a field in which the highest priority became the preparation of clinically capable persons for positions of leadership. Commonsense Psychiatry, written by Adolf Meyer, had great impact on psychiatry; however, it did not have a noticeable influence on psychiatric nursing. Nursing for the Future eliminated single-focus schools of psychiatric nursing. The Community Mental Health Centers Act of 1963 encouraged the closing of large mental hospitals and further encouraged the trend toward expanded nursing roles at the graduate level.

Rationale 4: The National Mental Health Act of 1946 is probably the most significant piece of legislation affecting the development of psychiatricmental health nursing. Within this act, psychiatric nursing was added to psychiatry, psychology, and social work as a field in which the highest priority became the preparation of clinically capable persons for positions of leadership. Commonsense Psychiatry, written by Adolf Meyer, had great impact on psychiatry; however, it did not have a noticeable influence on psychiatric nursing. Nursing for the Future eliminated single-focus schools of psychiatric nursing. The Community Mental Health Centers Act of 1963 encouraged the closing of large mental hospitals and further encouraged the trend toward expanded nursing roles at the graduate level.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: Describe how the role of the psychiatricmental health nurse changed over the years from that of custodian to a multifaceted role.

Question 21

Type: MCMA

The nurse is writing a scholarly paper on early nursing leaders who made major contributions to the development of the multifaceted psychiatric nursing role of today. The nurse should include which of the following nurses when writing the paper?

Standard Text: Select all that apply.

4. Gwen Tudor (Will)

5. Hildegard Peplau

Correct Answer: 4,5

Rationale 1: Florence Nightingale. Noted that the influence of nurses went beyond physical care; however, she emphasized physical care and made no other significant contributions to the role of the psychiatric nurse.

Rationale 2: Frances Sleeper. Advocated the use of psychiatric nurses as psychotherapists.

Rationale 3: Linda Richards. Worked toward better nursing care in psychiatric hospitals; however, had minimal impact on the current role of psychiatric nurses. Nurses of her era focused on more custodial physical nursing care.

Rationale 4: Gwen Tudor (Will). Designed a nursing intervention that demonstrated that nurses can promote emotional growth in clients and that the psychotherapeutic nursing role can be taught to others.

Rationale 5: Hildegard Peplau. Published Interpersonal Relations in Nursing, the first systematic theoretic framework in psychiatric nursing, a milestone in the development of the psychiatric nursing roles and practice.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Describe how the role of the psychiatricmental health nurse changed over the years from that of custodian to a multifaceted role.

Question 22

Type: MCMA

The psychiatric-mental health nurse is planning a personal program of continuing education to better meet the challenges of the future in psychiatric nursing practice. What areas should be included in the nurses plan for continuing education?

Standard Text: Select all that apply.

1. Psychiatric nursing care in nontraditional settings

2. Psychopharmacology

3. Genetic research

4. Psychobiology

5. Physical health of psychiatric clients

Correct Answer: 1,2,3,4,5

Rationale 1: Psychiatric nursing care in nontraditional settings. Settings continue to expand from hospitals and traditional settings to alternative and nontraditional settings.

Rationale 2: Psychopharmacology. Newer psychopharmacologic agents with fewer side effects continue to grow.

Rationale 3: Genetic research resulted in significant knowledge related to the genetic basis of inherited mental disorders that must be integrated into various areas of psychiatric nursing practice.

Rationale 4: Psychobiology. As there has been a knowledge explosion in psychobiology, the greatest challenge for psychiatric nursing is the integration of psychobiologic knowledge into clinical practice while maintaining a focus on caring.

Rationale 5: Physical health of psychiatric clients is a sometimes overlooked dimension of care especially among the severely and persistently mentally ill clients living in community settings is a new area of focus and challenge for psychiatric nurses.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: Describe how the role of the psychiatricmental health nurse changed over the years from that of custodian to a multifaceted role.

Question 23

Type: MCSA

While caring for the client with a mental illness, which action by the psychiatricmental health nurse best indicates use of Hildegard Peplaus nursing theory?

1. Establishing a therapeutic nurse-client relationship

2. Intervening to enhance the clients abilities to perform self-care

3. Assessing clients interactions with their environment

4. Evaluating the effectiveness of the clients coping and adaptation skills

Correct Answer: 1

Rationale 1: Peplau conceptualized the one-to-one nurseclient relationship in which the client can accomplish developmental tasks and practice healthy behaviors. Dorothea Orem identified the goal of self-care and focused on the clients abilities to perform self-care to maintain life, health, and well-being. Martha Rogers work gave psychiatric nurses a mandate to use holistic principles and to consider human beings and environmental interactions. Sister Callista Roys adaptation theory related the notion of coping or adapting to stimuli as humans interact with their environment.

Rationale 2: Peplau conceptualized the one-to-one nurseclient relationship in which the client can accomplish developmental tasks and practice healthy behaviors. Dorothea Orem identified the goal of self-care and focused on the clients abilities to perform self-care to maintain life, health, and well-being. Martha Rogers work gave psychiatric nurses a mandate to use holistic principles and to consider human beings and environmental interactions. Sister Callista Roys adaptation theory related the notion of coping or adapting to stimuli as humans interact with their environment.

Rationale 3: Peplau conceptualized the one-to-one nurseclient relationship in which the client can accomplish developmental tasks and practice healthy behaviors. Dorothea Orem identified the goal of self-care and focused on the clients abilities to perform self-care to maintain life, health, and well-being. Martha Rogers work gave psychiatric nurses a mandate to use holistic principles and to consider human beings and environmental interactions. Sister Callista Roys adaptation theory related the notion of coping or adapting to stimuli as humans interact with their environment.

Rationale 4: Peplau conceptualized the one-to-one nurseclient relationship in which the client can accomplish developmental tasks and practice healthy behaviors. Dorothea Orem identified the goal of self-care and focused on the clients abilities to perform self-care to maintain life, health, and well-being. Martha Rogers work gave psychiatric nurses a mandate to use holistic principles and to consider human beings and environmental interactions. Sister Callista Roys adaptation theory related the notion of coping or adapting to stimuli as humans interact with their environment.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: Discuss the nursing theory concepts and principles that have shaped psychiatricmental health nursing most directly.

Question 24

Type: MCSA

If psychiatric nurses used Orems theory for structuring much of their nursing practice, a major focus area for assessment would be the clients ability to do which of the following?

1. Adapt and function to meet various role expectations.

2. Care about self and participate in self-healing.

3. Implement self-care to meet psychosocial needs.

4. Enter into a therapeutic one-to-one relationship with the nurse.

Correct Answer: 3

Rationale 1: Orems theory of self-care identifies universal self-care requisites and categories that encompass both physical and psychosocial human needs. Orem focuses on abilities to perform self-care to maintain life, health, and well-being. Peplau conceptualizes the one-to-one nurseclient relationship. Roys adaptation theory identifies modes of human adapting, including the area of role function. Watsons theory of human caring emphasizes self-caring and self-healing.

Rationale 2: Orems theory of self-care identifies universal self-care requisites and categories that encompass both physical and psychosocial human needs. Orem focuses on abilities to perform self-care to maintain life, health, and well-being. Peplau conceptualizes the one-to-one nurseclient relationship. Roys adaptation theory identifies modes of human adapting, including the area of role function. Watsons theory of human caring emphasizes self-caring and self-healing.

Rationale 3: Orems theory of self-care identifies universal self-care requisites and categories that encompass both physical and psychosocial human needs. Orem focuses on abilities to perform self-care to maintain life, health, and well-being. Peplau conceptualizes the one-to-one nurseclient relationship. Roys adaptation theory identifies modes of human adapting, including the area of role function. Watsons theory of human caring emphasizes self-caring and self-healing.

Rationale 4: Orems theory of self-care identifies universal self-care requisites and categories that encompass both physical and psychosocial human needs. Orem focuses on abilities to perform self-care to maintain life, health, and well-being. Peplau conceptualizes the one-to-one nurseclient relationship. Roys adaptation theory identifies modes of human adapting, including the area of role function. Watsons theory of human caring emphasizes self-caring and self-healing.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Discuss the nursing theory concepts and principles that have shaped psychiatricmental health nursing most directly.

Question 25

Type: MCSA

The psychiatricmental health nurse is asked to develop an intervention for the nursing unit based on Watsons theory of caring. Given this assignment, which intervention is most appropriate for the nurse to implement?

1. One-to-one debriefing sessions each week with individual unit nurses and the unit manager

2. Clarification of values and cultural beliefs that might pose barriers to caring for clients

3. Identification of additional coping skills for new nurses on the unit

4. Discussion of the impact of recent changes in hospital policy on the nursing staff

Correct Answer: 2

Rationale 1: Watsons theory of human caring emphasizes sensitivity to self and values clarification regarding personal and cultural beliefs that might pose barriers to transpersonal caring. Identification of coping skills for new nurses is consistent with Roys theory of adaptation. Discussion of the impact of change on the nursing staff is consistent with Rogerss theory that considers humans and environmental interactions and change. One-to-one debriefing sessions are more consistent with Peplaus theory; however, this intervention could be used in a variety of theoretical approaches.

Rationale 2: Watsons theory of human caring emphasizes sensitivity to self and values clarification regarding personal and cultural beliefs that might pose barriers to transpersonal caring. Identification of coping skills for new nurses is consistent with Roys theory of adaptation. Discussion of the impact of change on the nursing staff is consistent with Rogerss theory that considers humans and environmental interactions and change. One-to-one debriefing sessions are more consistent with Peplaus theory; however, this intervention could be used in a variety of theoretical approaches.

Rationale 3: Watsons theory of human caring emphasizes sensitivity to self and values clarification regarding personal and cultural beliefs that might pose barriers to transpersonal caring. Identification of coping skills for new nurses is consistent with Roys theory of adaptation. Discussion of the impact of change on the nursing staff is consistent with Rogerss theory that considers humans and environmental interactions and change. One-to-one debriefing sessions are more consistent with Peplaus theory; however, this intervention could be used in a variety of theoretical approaches.

Rationale 4: Watsons theory of human caring emphasizes sensitivity to self and values clarification regarding personal and cultural beliefs that might pose barriers to transpersonal caring. Identification of coping skills for new nurses is consistent with Roys theory of adaptation. Discussion of the impact of change on the nursing staff is consistent with Rogerss theory that considers humans and environmental interactions and change. One-to-one debriefing sessions are more consistent with Peplaus theory; however, this intervention could be used in a variety of theoretical approaches.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Discuss the nursing theory concepts and principles that have shaped psychiatricmental health nursing most directly.

Question 26

Type: MCSA

The unit manager is consistently advocating for self-awareness among the psychiatricmental health nursing staff in order to promote quality care. From which theoretical base is the unit manager operating?

1. Jean Watsons theory of human caring

2. Dorothea Orems theory of self-care

3. Martha Rogerss principles of homeodynamics

4. Sister Callista Roys adaptation theory

Correct Answer: 1

Rationale 1: Jean Watsons theory of human caring emphasizes sensitivity to self and values clarification regarding personal and cultural beliefs that might pose as barriers to transpersonal caring. Roys adaptation theory (coping and adapting to environmental stimuli), Rogerss principles of homeodynamics (human and environmental interaction), and Orems theory of self-care (matching nursing systems of care with clients levels of self-care functioning) have different emphases.

Rationale 2: Jean Watsons theory of human caring emphasizes sensitivity to self and values clarification regarding personal and cultural beliefs that might pose as barriers to transpersonal caring. Roys adaptation theory (coping and adapting to environmental stimuli), Rogerss principles of homeodynamics (human and environmental interaction), and Orems theory of self-care (matching nursing systems of care with clients levels of self-care functioning) have different emphases.

Rationale 3: Jean Watsons theory of human caring emphasizes sensitivity to self and values clarification regarding personal and cultural beliefs that might pose as barriers to transpersonal caring. Roys adaptation theory (coping and adapting to environmental stimuli), Rogerss principles of homeodynamics (human and environmental interaction), and Orems theory of self-care (matching nursing systems of care with clients levels of self-care functioning) have different emphases.

Rationale 4: Jean Watsons theory of human caring emphasizes sensitivity to self and values clarification regarding personal and cultural beliefs that might pose as barriers to transpersonal caring. Roys adaptation theory (coping and adapting to environmental stimuli), Rogerss principles of homeodynamics (human and environmental interaction), and Orems theory of self-care (matching nursing systems of care with clients levels of self-care functioning) have different emphases.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: Discuss the nursing theory concepts and principles that have shaped psychiatricmental health nursing most directly.

Question 27

Type: MCSA

Upon the clients arrival on the patient care unit, the nurse begins implementation of the nursing process. Of which nursing theorist should the nurses practice be most reflective?

Correct Answer: 4

Rationale 1: Some say that the phases of Peplaus therapeutic nurseclient relationship are ancestors of the phases of the nursing process. While Orem, Watson, and Orlando guide the nurse in areas for assessment, analysis, planning, intervention, evaluation, etc., they do not identify specific phases or steps of the nurseclient interaction process.

Rationale 2: Some say that the phases of Peplaus therapeutic nurseclient relationship are ancestors of the phases of the nursing process. While Orem, Watson, and Orlando guide the nurse in areas for assessment, analysis, planning, intervention, evaluation, etc., they do not identify specific phases or steps of the nurseclient interaction process.

Rationale 3: Some say that the phases of Peplaus therapeutic nurseclient relationship are ancestors of the phases of the nursing process. While Orem, Watson, and Orlando guide the nurse in areas for assessment, analysis, planning, intervention, evaluation, etc., they do not identify specific phases or steps of the nurseclient interaction process.

Rationale 4: Some say that the phases of Peplaus therapeutic nurseclient relationship are ancestors of the phases of the nursing process. While Orem, Watson, and Orlando guide the nurse in areas for assessment, analysis, planning, intervention, evaluation, etc., they do not identify specific phases or steps of the nurseclient interaction process.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: Discuss the nursing theory concepts and principles that have shaped psychiatricmental health nursing most directly.

Question 28

Type: MCMA

The nursing student asks the nurse the reason that knowledge of nursing theories is important. The nurse should respond that nurses use nursing theories to do which of the following?

Standard Text: Select all that apply.

1. Organize assessment data.

2. Generate goals.

3. Evaluate outcomes.

4. Plan interventions.

5. Generate nursing actions.

Correct Answer: 1,2,4,5

Rationale 1: Organize assessment data. Nurses use theories to assist them to organize and think about human responses and data in meaningful ways.

Rationale 2: Generate goals. Nurses use theories to generate goals that have meaning for clients and reflect desired outcomes to promote health and well-being.

Rationale 3: Evaluate outcomes. Nurses use theories to assist in the identification of areas for evaluation of client progress toward goals.

Rationale 4: Plan interventions. Nurses use theories to plan interventions that address human responses as they interact with both the internal and external environments.

Rationale 5: Generate nursing actions. Nurses use theories to provide guidance in the focus for nursing actions that promote health as defined by each theory.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Explain why you should be capable of functioning in all theories of care.

Question 29

Type: MCSA

If the nurse is using the nursing theory that has shaped psychiatricmental health most directly, which nursing action is priority?

1. Assessing the clients abilities in areas of self-care

2. Teaching effective coping skills

3. Establishing a therapeutic nurseclient relationship

4. Encouraging the clients sensitivity and caring for self

Correct Answer: 3

Rationale 1: The interpersonal theory of psychiatricmental health nursing and the therapeutic relationship originated by Peplau remains the theory that has shaped psychiatricmental health nursing most directly. While assessing self-care abilities, encouraging sensitivity and caring for self, and teaching effective coping skills are important areas for nursing action, all efforts are supported by a therapeutic nurseclient relationship.

Rationale 2: The interpersonal theory of psychiatric-mental health nursing and the therapeutic relationship originated by Peplau remains the theory that has shaped psychiatricmental health nursing most directly. While assessing self-care abilities, encouraging sensitivity and caring for self, and teaching effective coping skills are important areas for nursing action, all efforts are supported by a therapeutic nurseclient relationship.

Rationale 3: The interpersonal theory of psychiatricmental health nursing and the therapeutic relationship originated by Peplau remains the theory that has shaped psychiatricmental health nursing most directly. While assessing self-care abilities, encouraging sensitivity and caring for self, and teaching effective coping skills are important areas for nursing action, all efforts are supported by a therapeutic nurseclient relationship.

Rationale 4: The interpersonal theory of psychiatricmental health nursing and the therapeutic relationship originated by Peplau remains the theory that has shaped psychiatricmental health nursing most directly. While assessing self-care abilities, encouraging sensitivity and caring for self, and teaching effective coping skills are important areas for nursing action, all efforts are supported by a therapeutic nurseclient relationship.

Chapter 2. The Neurophysiology of Trauma and Psychotherapy

Multiple Choice

1. A patient asks, What are neurotransmitters? The doctor said mine are imbalanced. Select the nurses best response.

a. How do you feel about having imbalanced neurotransmitters?

b. Neurotransmitters protect us from harmful effects of free radicals.

c. Neurotransmitters are substances we consume that influence memory and mood.

d. Neurotransmitters are natural chemicals that pass messages between brain cells.

ANS: D a. This test uses a magnetic field and gamma waves to identify problem areas in the brain. Does your teenager have any metal implants? b. PET means positron-emission tomography. It is a special type of scan that shows blood flow and activity in the brain. c. A PET scan passes an electrical current through the brain and shows brain-wave activity. It can help diagnose seizures. d. Its a special x-ray that shows structures of the brain and whether there has ever been a brain injury.

The patient asked for information, and the correct response is most accurate. Neurotransmitters are chemical substances that function as messengers in the central nervous system. They are released from the axon terminal, diffuse across the synapse, and attach to specialized receptors on the postsynaptic neuron. The distracters either do not answer the patients question or provide untrue, misleading information.

2. The parent of an adolescent diagnosed with schizophrenia asks the nurse, My childs doctor ordered a PET. What kind of test is that? Select the nurses best reply.

ANS: B a. Skull x-rays b. Computed tomography (CT) scan c. Positron-emission tomography (PET) d. Single-photon emission computed tomography (SPECT)

The parent is seeking information about PET scans. It is important to use terms the parent can understand, so the nurse should identify what the initials mean. The correct response is the only option that provides information relevant to PET scans. The distracters describe MRI, CT scans, and EEG. See relationship to audience response question.

3. A patient with a long history of hypertension and diabetes now develops confusion. The health care provider wants to make a differential diagnosis between Alzheimers disease and multiple infarcts. Which diagnostic procedure should the nurse expect to prepare the patient for first?

ANS: B a. Amydala c. Hippocampus b. Parietal lobe d. Hypothalamus

A CT scan shows the presence or absence of structural changes, including cortical atrophy, ventricular enlargement, and areas of infarct, information that would be helpful to the health care provider. PET and SPECT show brain activity rather than structure and may occur later. See relationship to audience response question.

4. A patients history shows drinking 4 to 6 liters of fluid and eating more than 6,000 calories per day. Which part of the central nervous system is most likely dysfunctional for this patient?

ANS: D a. Have you ever seen or heard things that others do not? b. What are your worst and best times of the day? c. How would you describe your thinking? d. Do you think your memory is failing?

The hypothalamus, a small area in the ventral superior portion of the brainstem, plays a vital role in such basic drives as hunger, thirst, and sex. See relationship to audience response question.

5. The nurse prepares to assess a patient diagnosed with major depression for disturbances in circadian rhythms. Which question should the nurse ask this patient?

ANS: B a. Reduced anxiety b. Improved memory

Mood changes throughout the day may be related to circadian rhythm disturbances. Questions about sleep pattern are also relevant to circadian rhythms. The distracters apply to assessment for illusions and hallucinations, thought processes, and memory.

6. The nurse administers a medication that potentiates the action of gamma-aminobutyric acid (GABA). Which effect would be expected?

ANS: A c. More organized thinking d. Fewer sensory perceptual alterations

Increased levels of GABA reduce anxiety. Acetylcholine and substance P are associated with memory enhancement. Thought disorganization is associated with dopamine. GABA is not associated with sensory perceptual alterations. See relationship to audience response question.

7. A nurse would anticipate that treatment for a patient with memory difficulties might include medications designed to: a. inhibit gamma-aminobutyric acid (GABA). b. prevent destruction of acetylcholine. c. reduce serotonin metabolism. d. increase dopamine activity.

ANS: B a. Hippocampus b. Frontal lobe

Increased acetylcholine plays a role in learning and memory. Preventing destruction of acetylcholine by acetylcholinesterase would result in higher levels of acetylcholine, with the potential for improved memory. GABA affects anxiety rather than memory. Increased dopamine would cause symptoms associated with schizophrenia or mania rather than improve memory. Decreasing dopamine at receptor sites is associated with Parkinsons disease rather than improving memory.

8. A patient has disorganized thinking associated with schizophrenia. Neuroimaging would likely show dysfunction in which part of the brain?

ANS: B c. Cerebellum d. Brainstem

The frontal lobe is responsible for intellectual functioning. The hippocampus is involved in emotions and learning. The cerebellum regulates skeletal muscle coordination and equilibrium. The brainstem regulates internal organs.

9. The nurse should assess a patient taking a drug with anticholinergic properties for inhibited function of the: a. parasympathetic nervous system. c. reticular activating system. b. sympathetic nervous system. d. medulla oblongata.

ANS: A

Acetylcholine is the neurotransmitter found in high concentration in the parasympathetic nervous system. When anticholinergic drugs inhibit acetylcholine action, blurred vision, dry mouth, constipation, and urinary retention commonly occur.

10. The therapeutic action of neurotransmitter inhibitors that block reuptake cause: a. decreased concentration of the blocked neurotransmitter in the central nervous system. b. increased concentration of the blocked neurotransmitter in the synaptic gap. c. destruction of receptor sites specific to the blocked neurotransmitter. d. limbic system stimulation.

ANS: B a. Anticholinergic effects b. Dopamine-blocking effects

If the reuptake of a substance is inhibited, it accumulates in the synaptic gap, and its concentration increases, permitting ease of transmission of impulses across the synaptic gap. Normal transmission of impulses across synaptic gaps is consistent with normal rather than depressed mood. The other options are not associated with blocking neurotransmitter reuptake.

11. A patient taking medication for mental illness develops restlessness and an uncontrollable need to be in motion. Which drug action causes these symptoms to develop?

ANS: B c. Endocrine-stimulating effects d. Ability to stimulate spinal nerves a. Gamma-aminobutyric acid (GABA) b. Norepinephrine

Medication that blocks dopamine often produces disturbances of movement, such as akathisia, because dopamine affects neurons involved in both thought processes and movement regulation. Anticholinergic effects include dry mouth, blurred vision, urinary retention, and constipation. Akathisia is not caused by endocrine stimulation or spinal nerve stimulation.

12. A patient has fear as well as increased heart rate and blood pressure. The nurse suspects increased activity of which neurotransmitter?

ANS: B c. Acetylcholine d. Histamine a. Tricyclic antidepressants b. Antipsychotic drugs

Norepinephrine is the neurotransmitter associated with sympathetic nervous system stimulation, preparing the individual for fight or flight. GABA is a mediator of anxiety level. A high concentration of histamine is associated with an inflammatory response. A high concentration of acetylcholine is associated with parasympathetic nervous system stimulation.

13. A patient has acute anxiety related to an automobile accident 2 hours ago. The nurse should teach the patient about medication from which group?

ANS: D c. Antimanic drugs d. Benzodiazepines

Benzodiazepines provide anxiety relief. Tricyclic antidepressants are used to treat symptoms of depression. Antimanic drugs are used to treat bipolar disorder. Antipsychotic drugs are used to treat psychosis.

14. A patient is hospitalized for severe depression. Of the medications listed below, the nurse can expect to provide the patient with teaching about: a. chlordiazepoxide (Librium). b. clozapine (Clozaril).

ANS: C c. sertraline (Zoloft). d. tacrine (Cognex). a. Psychostimulants b. Mood stabilizers c. Anticholinergics d. Antidepressants

Sertraline (Zoloft) is an SSRI. This antidepressant blocks the reuptake of serotonin, with few anticholinergic and sedating side effects. Clozapine is an antipsychotic. Chlordiazepoxide is an anxiolytic. Tacrine treats Alzheimers disease.

15. A patient diagnosed with bipolar disorder has an unstable mood, aggressiveness, agitation, talkativeness, and irritability. The nurse expects the health care provider to prescribe a medication from which group?

ANS: B

The symptoms describe mania, which is effectively treated by mood stabilizers, such as lithium, and selected anticonvulsants (carbamazepine, valproic acid, and lamotrigine). Drugs from the other classifications listed are not effective in the treatment of mania.

16. A drug causes muscarinic receptor blockade. The nurse will assess the patient for: a. dry mouth. b. gynecomastia.

ANS: A c. pseudoparkinsonism. d. orthostatic hypotension. a. Chew sugarless gum. b. Increase dietary fiber.

Muscarinic receptor blockade includes atropine-like side effects, such as dry mouth, blurred vision, and constipation. Gynecomastia is associated with decreased prolactin levels. Movement defects are associated with dopamine blockade. Orthostatic hypotension is associated with 1 antagonism.

17. A patient begins therapy with a phenothiazine medication. What teaching should the nurse provide related to the drugs strong dopaminergic effect?

ANS: D c. Arise slowly from bed. d. Report changes in muscle movement.

Phenothiazines block dopamine receptors in both the limbic system and basal ganglia. Movement disorders and motor abnormalities (extrapyramidal side effects), such as parkinsonism, akinesia, akathisia, dyskinesia, and tardive dyskinesia, are likely to occur early in the course of treatment. They are often heralded by sensations of muscle stiffness. Early intervention with antiparkinsonism medication can increase the patients comfort and prevent dystonic reactions. The distracters are related to anticholinergic effects.

18. A patient tells the nurse, My doctor prescribed Paxil (paroxetine) for my depression. I assume Ill have side effects like I had when I was taking Tofranil (imipramine). The nurses reply should be based on the knowledge that paroxetine is a(n): a. selective norepinephrine reuptake inhibitor. b. tricyclic antidepressant. c. MAO inhibitor.

ANS: D

Paroxetine is an SSRI and will not produce the same side effects as imipramine, a tricyclic antidepressant. The patient will probably not experience dry mouth, constipation, or orthostatic hypotension.

19. A nurse can anticipate anticholinergic side effects are likely when a patient takes: a. lithium (Lithobid). b. buspirone (BuSpar).

ANS: C c. imipramine (Tofranil). d. risperidone (Risperdal). a. Avoid unprotected sex. b. Report sore throat and fever immediately. c. Reduce foods high in polyunsaturated fats. d. Use over-the-counter preparations for rashes.

Imipramine (Tofranil) is a tricyclic antidepressant with strong anticholinergic properties, resulting in dry mouth, blurred vision, constipation, and urinary retention. Lithium therapy is more often associated with fluid-balance problems, including polydipsia, polyuria, and edema. Risperidone therapy is more often associated with movement disorders, orthostatic hypotension, and sedation. Buspirone is associated with anxiety reduction without major side effects.

20. Which instruction has priority when teaching a patient about clozapine (Clozaril)?

ANS: B

Clozapine therapy may produce agranulocytosis; therefore, signs of infection should be immediately reported to the health care provider. In addition, the patient should have white blood cell levels measured weekly. The other options are not relevant to clozapine.

21. A nurse cares for a group of patients receiving various medications, including haloperidol (Haldol), carbamazepine (Tegretol), trazodone (Desyrel), and phenelzine (Nardil). The nurse will order a special diet for the patient who takes: a. carbamazepine. b. haloperidol. c. phenelzine. d. trazodone.

ANS: C

Patients taking phenelzine, an MAO inhibitor, must be on a low tyramine diet to prevent hypertensive crisis. There are no specific dietary precautions associated with the distracters.

22. A nurse instructs a patient taking a drug that inhibits monoamine oxidase (MAO) to avoid certain foods and drugs because of the risk of: a. cardiac dysrhythmia. b. hypotensive shock.

ANS: C c. hypertensive crisis. d. hypoglycemia.

Patients taking MAO-inhibiting drugs must be on a low tyramine diet to prevent hypertensive crisis. In the presence of MAO inhibitors, tyramine is not destroyed by the liver and in high levels produces intense vasoconstriction, resulting in elevated blood pressure.

23. A nurse caring for a patient taking a selective serotonin reuptake inhibitor (SSRI) will develop outcome criteria related to: a. coherent thought processes. b. improvement in depression.

ANS: B c. reduced levels of motor activity. d. decreased extrapyramidal symptoms. a. Destroying increased amounts of serotonin b. Making more serotonin available at the synaptic gap c. Increasing production of acetylcholine and dopamine d. Blocking muscarinic and 1 norepinephrine receptors

SSRIs affect mood, relieving depression in many cases. SSRIs do not act to reduce thought disorders. SSRIs reduce depression but have little effect on motor hyperactivity. SSRIs do not produce extrapyramidal symptoms.

24. By which mechanism do selective serotonin reuptake inhibitors (SSRI) improve depression?

ANS: B a. Report the results to the health care provider immediately. b. Administer the next dose as prescribed. c. Give aspirin and force fluids. d. Repeat the laboratory test.

Depression is thought to be related to lowered availability of the neurotransmitter serotonin. SSRIs act by blocking reuptake of serotonin, leaving a higher concentration available at the synaptic cleft. SSRIs prevent destruction of serotonin. SSRIs have little or no effect on acetylcholine and dopamine production. SSRIs do not produce muscarinic or 1 norepinephrine blockade.

25. The laboratory report for a patient taking clozapine (Clozaril) shows a white blood cell count of 3000 mm3 . Select the nurses best action.

ANS: A

These laboratory values indicate the possibility of agranulocytosis, a serious side effect of clozapine therapy. These results must be immediately reported to the health care provider, and the drug should be withheld. The health care provider may repeat the test, but in the meantime, the drug should be withheld. Caution: This question requires students to apply previous learning regarding normal and abnormal values of white blood cell counts.

26. A drug blocks the attachment of norepinephrine to 1 receptors. The patient may experience: a. hypertensive crisis. b. orthostatic hypotension.

ANS: B c. severe appetite disturbance. d. an increase in psychotic symptoms.

Sympathetic-mediated vasoconstriction is essential for maintaining normal blood pressure in the upright position. Blockage of 1 receptors leads to vasodilation and orthostatic hypotension. Orthostatic hypotension may cause fainting and falls. Teach patients ways of minimizing this phenomenon.

27. A nurse cares for four patients who are receiving clozapine, lithium, fluoxetine, and venlafaxine, respectively. With which patient should the nurse be most alert for problems associated with fluid and electrolyte imbalance? The patient receiving: a. lithium (Lithobid). b. clozapine (Clozaril). c. fluoxetine (Prozac). d. venlafaxine (Effexor).

ANS: A a. H1 b. 5 HT2

Lithium is a salt and known to alter fluid and electrolyte balance, producing polyuria, edema, and other symptoms of imbalance. Patients receiving clozapine should be monitored for agranulocytosis. Patients receiving fluoxetine should be monitored for acetylcholine block. Patients receiving venlafaxine should be monitored for heightened feelings of anxiety.

28. An obese patient has a diagnosis of schizophrenia. Medications that block which receptors would contribute to further weight gain?

ANS: A c. Acetylcholine d. Gamma-aminobutyric acid (GABA) a. Pulse rate changes from 90 to 72. b. Respiratory rate changes from 22 to 18. c. Complaints of intestinal cramping begin. d. Blood pressure changes from 114/62 to 136/78.

H1 receptor blockade results in weight gain, which is undesirable for an obese patient. Blocking of the other receptors would have little or no effect on the patients weight.

29. An individual hiking in the forest encounters a large poisonous snake on the path. Which change in this individuals vital signs is most likely?

ANS: D a. Galantamine (Reminyl) b. Valproate (Depakote) c. Buspirone (BuSpar) d. Tacrine (Cognex)

This frightening experience would stimulate the sympathetic nervous system, causing a release of norepinephrine, an excitatory neurotransmitter. It prepares the body for fight or flight. Increased blood pressure, pupil size, respiratory rate, and pulse rate signify release of norepinephrine. Intestinal cramping would be associated with stimulation of the parasympathetic nervous system.

30. Consider these medications: carbamazepine (Tegretol), lamotrigine (Lamictal), gabapentin (Neurontin). Which medication below also belongs with this group?

ANS: B a. Write the appointment day, time, and location on a piece of paper and give it to the player. b. Log the appointment day, time, and location into the players cell phone calendar feature. c. Ask the health care provider to admit the patient to the hospital overnight. d. Verbally inform the patient of the appointment day, time, and location.

The medications listed in the stem are mood stabilizers, anticonvulsant types. Valproate (Depakote) is also a member of this group. The distracters are drugs for treatment of Alzheimers disease and anxiety.

31. A professional football player is seen in the emergency department after losing consciousness from an illegal block. Prior to discharge, the nurse assists the patient to schedule an outpatient computed tomography (CT) scan for the next day. Which strategy should the nurse use to ensure the patient remembers the appointment?

ANS: B

This player may have suffered repeated head injuries with damage to the hippocampus. The hippocampus has significant role in maintaining memory. Logging the appointment into the players cell phone calendar will remind him of the appointment the next day. Paper will be lost, and the patient is unlikely to remember verbal instruction. Hospitalization is unnecessary. See relationship to audience response question. Caution: This question requires students to apply previous learning regarding central nervous system anatomy and physiology.

Multiple Response

1. A nurse prepares to administer a second-generation antipsychotic medication to a patient diagnosed with schizophrenia. Additional monitoring for adverse effects will be most important if the patient has which comorbid health problems? Select all that apply.

a. Parkinsons disease b. Graves disease c. Hyperlipidemia d. Osteoarthritis e. Diabetes

ANS: A, C, E

Antipsychotic medications may produce weight gain, which would complicate care of a patient with diabetes, and increase serum triglycerides, which would complicate care of a patient with hyperlipidemia. Parkinsons disease involves changes in transmission of dopamine and acetylcholine, so these drugs would also complicate care of this patient. Osteoarthritis and Graves disease should have no synergistic effect with this medication.

2. Questions the nurse could ask that would be nonjudgmental when obtaining information about patient use of herbal remedies include: (select all that apply) a. You dont regularly take herbal remedies, do you? b. What herbal medicines have you used to relieve your symptoms? c. What over-the-counter medicines and nutritional supplements do you use? d. What differences in your symptoms do you notice when you take herbal supplements? e. Have you experienced problems from using herbal and prescription drugs at the same time?

ANS: B, C, D, E a. Amygdala b. Hippocampus c. Occipital lobe d. Temporal lobe e. Basal ganglia

The correct responses are neutral in tone and do not express bias for or against the use of herbal medicines. The distracter, worded in a negative way, makes the nurses bias evident.

3. An individual is experiencing problems with memory. Which of these structures are most likely to be involved in this deficit? Select all that apply.

ANS: A, B, D a. Sometimes there are physical causes for psychiatric symptoms. This test will help us understand whether that is the situation. b. Some mental illnesses are evident on fMRIs. This test will give information to help us plan the best care for your brother. c. Tell me more about what kinds of tests your brothers health insurance plan covers. d. It sounds like you do not truly believe your brother had a mental illness. e. It would be better for you to discuss your concerns with the doctor.

The frontal, parietal, and temporal lobes of the cerebrum play a key role in the storage and processing of memories. The amygdala and hippocampus also play roles in memory. The occipital lobe is predominantly involved with vision. The basal ganglia influence integration of physical movement, as well as some thoughts and emotions.

4. A patients sibling says, My brother has a mental illness, but the doctor ordered a functional magnetic resonance image (fMRI) test. That test is too expensive and will just increase the hospital bill. Select the nurses best responses. Select all that apply.

ANS: A, B

The correct responses provide information to the sibling. Modern imaging techniques are important tools in assessing molecular changes in mental disease and marking the receptor sites of drug action, which can help in treatment planning. Psychiatric symptoms can be caused by anatomical or physiologic abnormalities. There is no evidence of denial in the siblings comment. The nurse can answer this question rather than referring it to the physician. It would be inappropriate to discuss finances with the patients sibling.

Chapter 3. Assessment and Diagnosis

Question 1

Type: MCSA

Which of the following best describes the information the nurse will use to construct a nursing care plan?

1. A mental status examination

2. An intake assessment and reason for admission

3. A psychiatric history and mental status examination

4. A detailed psychiatric history

Correct Answer: 3

Rationale 1: The psychiatric examination consists of the psychiatric history and mental status examination. The intake assessment and reason for admission are part of the psychiatric history, which includes the clients current condition, previous diagnosis, interventions, treatments, and a family history.

Rationale 2: The psychiatric examination consists of the psychiatric history and mental status examination. The intake assessment and reason for admission are part of the psychiatric history, which includes the clients current condition, previous diagnosis, interventions, treatments, and a family history.

Rationale 3: The psychiatric examination consists of the psychiatric history and mental status examination. The intake assessment and reason for admission are part of the psychiatric history, which includes the clients current condition, previous diagnosis, interventions, treatments, and a family history.

Rationale 4: The psychiatric examination consists of the psychiatric history and mental status examination. The intake assessment and reason for admission are part of the psychiatric history, which includes the clients current condition, previous diagnosis, interventions, treatments, and a family history.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: Perform an ongoing psychiatricmental health assessment of clients in your care.

Question 2

Type: MCSA

A nursing student is working to develop assessment skills. The student knows that nurses utilize principles of assessment:

1. Upon admission.

2. Throughout hospitalization.

3. At the point of entry to care.

4. Prior to discharge.

Correct Answer: 2

Rationale 1: Assessment is essential to the delivery of nursing care and is included at all phases of a clients hospitalization, beginning at the point of entry to care through discharge.

Rationale 2: Assessment is essential to the delivery of nursing care and is included at all phases of a clients hospitalization, beginning at the point of entry to care through discharge.

Rationale 3: Assessment is essential to the delivery of nursing care and is included at all phases of a clients hospitalization, beginning at the point of entry to care through discharge.

Rationale 4: Assessment is essential to the delivery of nursing care and is included at all phases of a clients hospitalization, beginning at the point of entry to care through discharge.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Determine how and when to apply assessment principles in professional practice.

Question 3

Type: MCMA

A nurse who is admitting a client to the inpatient unit conducts a comprehensive assessment. How does the nurse use the data gathered from the assessment?

Standard Text: Select all that apply.

1. To support nursing diagnoses

2. To determine the length of stay

3. To exclude data from secondary sources

4. To plan appropriate interventions

5. To make sound clinical judgments

Correct Answer: 1,4,5

Rationale 1: To support nursing diagnoses. Data obtained from the comprehensive assessment is used as support or evidence for the nursing diagnoses.

Rationale 2: To determine the length of stay. The length of stay may be estimated at the time of admission, but the determining factor is the clients progression in response to care.

Rationale 3: To exclude data from secondary sources. Data are obtained from both primary (client) and secondary (other) sources.

Rationale 4: To plan appropriate interventions. Assessment data are used in planning appropriate interventions related to the clients need(s).

Rationale 5: To make sound clinical judgments. Information obtained from the comprehensive assessment is used to make clinical decisions related to the clients need(s).

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: Determine how and when to apply assessment principles in professional practice.

Question 4

Type: MCSA

As part of the comprehensive admission assessment, the nurse talks with family and friends who may contribute additional data to a clients psychiatric history. When reviewing the data obtained from these sources, the nurse keeps in mind which of the following perspectives of the data? The information provided:

1. Will vary according to the sources relationship to the client.

2. Comes from each individuals perspective.

3. Is considered false.

4. Is considered accurate.

Correct Answer: 2

Rationale 1: Family and friends have their own perspectives through which they filter events. The sources of the information to be included in the psychiatric history and the sources relationship to the client should always be clearly indicated. Information given by these collateral sources should be reviewed and understood in terms of that relationship.

Rationale 2: Family and friends have their own perspectives through which they filter events. The sources of the information to be included in the psychiatric history and the sources relationship to the client should always be clearly indicated. Information given by these collateral sources should be reviewed and understood in terms of that relationship.

Rationale 3: Family and friends have their own perspectives through which they filter events. The sources of the information to be included in the psychiatric history and the sources relationship to the client should always be clearly indicated. Information given by these collateral sources should be reviewed and understood in terms of that relationship.

Rationale 4: Family and friends have their own perspectives through which they filter events. The sources of the information to be included in the psychiatric history and the sources relationship to the client should always be clearly indicated. Information given by these collateral sources should be reviewed and understood in terms of that relationship.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Elicit a psychiatric history from a client and the clients family.

Question 5

Type: MCSA

The nurse reviews the data family and friends provided in the comprehensive assessment of a clients situation. The nurse knows to treat the data as:

1. Invalid until confirmed with the client.

2. Subjective data.

3. Primary data.

4. Peripheral to the assessment.

Correct Answer: 2

Rationale 1: Information provided by family and friends is subjective, secondary data. Information from family and friends is not peripheral, but is treated as important data to be contributed to the whole assessment while recognizing that it does not provide a total picture of the client. Secondary data does not need to be confirmed with the client.

Rationale 2: Information provided by family and friends is subjective, secondary data. Information from family and friends is not peripheral, but is treated as important data to be contributed to the whole assessment while recognizing that it does not provide a total picture of the client. Secondary data does not need to be confirmed with the client.

Rationale 3: Information provided by family and friends is subjective, secondary data. Information from family and friends is not peripheral, but is treated as important data to be contributed to the whole assessment while recognizing that it does not provide a total picture of the client. Secondary data does not need to be confirmed with the client.

Rationale 4: Information provided by family and friends is subjective, secondary data. Information from family and friends is not peripheral, but is treated as important data to be contributed to the whole assessment while recognizing that it does not provide a total picture of the client. Secondary data does not need to be confirmed with the client.

Global Rationale:

Cognitive Level: Applying

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Elicit a psychiatric history from a client and the clients family.

Question 6

Type: MCSA

The nurse is talking with the family of a mentally ill client who lives with them. The client is being admitted to the inpatient psychiatric unit. What is the priority information to gather from the family?

1. Whether the client had a flu shot recently

2. The number of medications prescribed for the client

3. How the clients symptoms are expressed at home

4. The type of soap the client prefers to use

Correct Answer: 3

Rationale 1: The most important information to be obtained from the family at the time of admission is how the symptoms of the clients illness are being expressed at home. This would be closely aligned to the chief complaint and provides a baseline for monitoring. The other information may be needed, but it is not the most important at the time of admission.

Rationale 2: The most important information to be obtained from the family at the time of admission is how the symptoms of the clients illness are being expressed at home. This would be closely aligned to the chief complaint and provides a baseline for monitoring. The other information may be needed, but it is not the most important at the time of admission.

Rationale 3: The most important information to be obtained from the family at the time of admission is how the symptoms of the clients illness are being expressed at home. This would be closely aligned to the chief complaint and provides a baseline for monitoring. The other information may be needed, but it is not the most important at the time of admission.

Rationale 4: The most important information to be obtained from the family at the time of admission is how the symptoms of the clients illness are being expressed at home. This would be closely aligned to the chief complaint and provides a baseline for monitoring. The other information may be needed, but it is not the most important at the time of admission.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Elicit a psychiatric history from a client and the clients family.

Question 7

Type: MCMA

The psychiatric examination includes a psychiatric history and a mental status assessment. When conducting the mental status assessment, the nurse:

Standard Text: Select all that apply.

1. Includes observations.

2. Limits the assessment to verbal responses.

3. Provides the client with a form to complete.

4. May or may not follow a strict sequence.

5. Uses a group format.

Correct Answer: 1,4

Rationale 1: Includes observations. Several components of the assessment require observational skills of the nurse.

Rationale 2: Limits the assessment to verbal responses. Observations of the clients nonverbal communication and other behaviors made by the nurse are included in the assessment.

Rationale 3: Provides the client with a form to complete. The nurse conducts the mental status assessment; the client is not given a form to complete.

Rationale 4: May or may not follow a strict sequence. The nurse is not required to follow a strict sequence or format.

Rationale 5: Uses a group format. The client is not assessed during group sessions, but the client is assessed during a one-to-one interaction.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Conduct a mental status examination on a client.

Question 8

Type: MCSA

A client makes the following statement during a mental status assessment: I cant use the phones; the CIA has bugged all the wires. Which of the following categories will the nurse use to document the clients response?

1. Orientation

2. Content of thought

3. Emotional state

4. General behavior

Correct Answer: 2

Rationale 1: Content of thought includes special preoccupations and experiences, including delusions. General behavior describes the clients physical characteristics. Emotional state refers to the persons pervasive or dominant mood. Orientation includes time, place, person, and self or purpose.

Rationale 2: Content of thought includes special preoccupations and experiences, including delusions. General behavior describes the clients physical characteristics. Emotional state refers to the persons pervasive or dominant mood. Orientation includes time, place, person, and self or purpose.

Rationale 3: Content of thought includes special preoccupations and experiences, including delusions. General behavior describes the clients physical characteristics. Emotional state refers to the persons pervasive or dominant mood. Orientation includes time, place, person, and self or purpose.

Rationale 4: Content of thought includes special preoccupations and experiences, including delusions. General behavior describes the clients physical characteristics. Emotional state refers to the persons pervasive or dominant mood. Orientation includes time, place, person, and self or purpose.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Conduct a mental status examination on a client.

Question 9

Type: MCSA

During a mental status assessment, the examiner asks the client to repeat these words: motorcar, teacup, and lilies. Five minutes later the client is asked to repeat the words again. The purpose of this exercise is to test the clients:

1. Insight.

2. Retention and recall.

3. Recall of recent past experiences.

Correct Answer: 2

Rationale 1: Retention and recall is used to test immediate impressions. Recall of recent past experiences relates to the events leading to the present seeking of treatment. Abstract thinking relates to the clients ability to interpret simple fables of proverbs. Insight provides information about the clients ability to recognize the significance of the present situation.

Rationale 2: Retention and recall is used to test immediate impressions. Recall of recent past experiences relates to the events leading to the present seeking of treatment. Abstract thinking relates to the clients ability to interpret simple fables of proverbs. Insight provides information about the clients ability to recognize the significance of the present situation.

Rationale 3: Retention and recall is used to test immediate impressions. Recall of recent past experiences relates to the events leading to the present seeking of treatment. Abstract thinking relates to the clients ability to interpret simple fables of proverbs. Insight provides information about the clients ability to recognize the significance of the present situation.

Rationale 4: Retention and recall is used to test immediate impressions. Recall of recent past experiences relates to the events leading to the present seeking of treatment. Abstract thinking relates to the clients ability to interpret simple fables of proverbs. Insight provides information about the clients ability to recognize the significance of the present situation.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Conduct a mental status examination on a client.

Question 10

Type: MCSA

An anxious client is to complete the Minnesota Multiphasic Personality Inventory-2 as part of the psychological testing. The client is worried about not having enough time to prepare for the test. To decrease anxiety, the nurse reviews the purpose of the test and explains that the client will:

1. Just need to complete a series of sentences.

2. Interpret ink blots.

3. Only have to copy geometric designs.

4. Be answering true or false questions.

Correct Answer: 4

Rationale 1: The MMPI-2 contains true or false questions. The Rorschach test involves the interpretation of ink blots. The Mini-Mental State Exam measures the ability to copy geometric designs. The Sentence Completion Test requires the completion of a series of sentences.

Rationale 2: The MMPI-2 contains true or false questions. The Rorschach test involves the interpretation of ink blots. The Mini-Mental State Exam measures the ability to copy geometric designs. The Sentence Completion Test requires the completion of a series of sentences.

Rationale 3: The MMPI-2 contains true or false questions. The Rorschach test involves the interpretation of ink blots. The Mini-Mental State Exam measures the ability to copy geometric designs. The Sentence Completion Test requires the completion of a series of sentences.

Rationale 4: The MMPI-2 contains true or false questions. The Rorschach test involves the interpretation of ink blots. The Mini-Mental State Exam measures the ability to copy geometric designs. The Sentence Completion Test requires the completion of a series of sentences.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Describe the essential components of physiological assessment, neurologic assessment, psychological testing, and psychosocial assessment.

Question 11

Type: MCSA

A family member reports that his mother has started hiding valuables around the house, then cant remember where she put them. He asks the nurse to explain what is happening. Which of the following assessment tools might the nurse utilize to screen the mother for signs of cognitive dysfunction?

1. Benton Visual Retention Test

2. Thematic Apperception Test

3. Ravens Progressive Matrices Test

4. Sentence Completion Test

Correct Answer: 1

Rationale 1: The Benton Visual Retention Test is an example of a neuropsychological assessment instrument that can yield valuable data on aspects of a persons cognitive functioning. It is sometimes used as a quick screening device to see if the test taker may be manifesting signs of cognitive dysfunction. The Sentence Completion Test asks clients to complete an extensive series of incomplete sentences with the first thoughts that come to mind. The sentences are designed to elicit responses concerning fantasies, fears, daydreams, and aspirations, among other things, and are not used to screen for cognitive dysfunction. The Thematic Apperception Test is used to reveal very important information about the clients emotional and interpersonal tendencies and not as a screening tool for signs of cognitive dysfunction. Ravens Progressive Matrices Test is designed to provide data on intellectual ability in a relatively culturally unbiased manner and is not used to screen for cognitive dysfunction.

Rationale 2: The Benton Visual Retention Test is an example of a neuropsychological assessment instrument that can yield valuable data on aspects of a persons cognitive functioning. It is sometimes used as a quick screening device to see if the test taker may be manifesting signs of cognitive dysfunction. The Sentence Completion Test asks clients to complete an extensive series of incomplete sentences with the first thoughts that come to mind. The sentences are designed to elicit responses concerning fantasies, fears, daydreams, and aspirations, among other things, and are not used to screen for cognitive dysfunction. The Thematic Apperception Test is used to reveal very important information about the clients emotional and interpersonal tendencies and not as a screening tool for signs of cognitive dysfunction. Ravens Progressive Matrices Test is designed to provide data on intellectual ability in a relatively culturally unbiased manner and is not used to screen for cognitive dysfunction.

Rationale 3: The Benton Visual Retention Test is an example of a neuropsychological assessment instrument that can yield valuable data on aspects of a persons cognitive functioning. It is sometimes used as a quick screening device to see if the test taker may be manifesting signs of cognitive dysfunction. The Sentence Completion Test asks clients to complete an extensive series of incomplete sentences with the first thoughts that come to mind. The sentences are designed to elicit responses concerning fantasies, fears, daydreams, and aspirations, among other things, and are not used to screen for cognitive dysfunction. The Thematic Apperception Test is used to reveal very important information about the clients emotional and interpersonal tendencies and not as a screening tool for signs of cognitive dysfunction. Ravens Progressive Matrices Test is designed to provide data on intellectual ability in a relatively culturally unbiased manner and is not used to screen for cognitive dysfunction.

Rationale 4: The Benton Visual Retention Test is an example of a neuropsychological assessment instrument that can yield valuable data on aspects of a persons cognitive functioning. It is sometimes used as a quick screening device to see if the test taker may be manifesting signs of cognitive dysfunction. The Sentence Completion Test asks clients to complete an extensive series of incomplete sentences with the first thoughts that come to mind. The sentences are designed to elicit responses concerning fantasies, fears, daydreams, and aspirations, among other things, and are not used to screen for cognitive dysfunction. The Thematic Apperception Test is used to reveal very important information about the clients emotional and interpersonal tendencies and not as a screening tool for signs of cognitive dysfunction. Ravens Progressive Matrices Test is designed to provide data on intellectual ability in a relatively culturally unbiased manner and is not used to screen for cognitive dysfunction.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Describe the essential components of physiological assessment, neurologic assessment, psychological testing, and psychosocial assessment.

Question 12

Type: MCSA

A depressed client asks why a physical exam is necessary before being admitted for outpatient treatment. The nurse explains to the client that a physical exam will:

1. Provide information about medications the client will need.

2. Make sure the client gets all necessary treatment.

3. Complete the admission process.

4. Ensure the client has not ingested any caustic material or inhaled noxious vapors.

Correct Answer: 2

Rationale 1: The clients symptoms may be due to a biological or neurological problem causing depressive symptoms. The value of careful assessment of general health issues and screening for biologic disorders cannot be overemphasized; in some community settings, psychiatric-mental health nurses are the only mental health care providers prepared to undertake such an assessment and interpret the results. The exams scope is not limited to exposure to dangerous chemicals, nor is it performed solely to comply with institutional policy. Its findings will guide all aspects of the clients care, not just medication therapy.

Rationale 2: The clients symptoms may be due to a biological or neurological problem causing depressive symptoms. The value of careful assessment of general health issues and screening for biologic disorders cannot be overemphasized; in some community settings, psychiatricmental health nurses are the only mental health care providers prepared to undertake such an assessment and interpret the results. The exams scope is not limited to exposure to dangerous chemicals, nor is it performed solely to comply with institutional policy. Its findings will guide all aspects of the clients care, not just medication therapy.

Rationale 3: The clients symptoms may be due to a biological or neurological problem causing depressive symptoms. The value of careful assessment of general health issues and screening for biologic disorders cannot be overemphasized; in some community settings, psychiatric-mental health nurses are the only mental health care providers prepared to undertake such an assessment and interpret the results. The exams scope is not limited to exposure to dangerous chemicals, nor is it performed solely to comply with institutional policy. Its findings will guide all aspects of the clients care, not just medication therapy.

Rationale 4: The clients symptoms may be due to a biological or neurological problem causing depressive symptoms. The value of careful assessment of general health issues and screening for biologic disorders cannot be overemphasized; in some community settings, psychiatric-mental health nurses are the only mental health care providers prepared to undertake such an assessment and interpret the results. The exams scope is not limited to exposure to dangerous chemicals, nor is it performed solely to comply with institutional policy. Its findings will guide all aspects of the clients care, not just medication therapy.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Describe the essential components of physiological assessment, neurologic assessment, psychological testing, and psychosocial assessment.

Question 13

Type: MCSA

The nurse in the community mental health clinic assesses a client and determines the presence of an Axis II diagnosis. What conclusions can the nurse draw?

1. The client is in need of further evaluation.

2. The client has a personality disorder.

3. The client will need a special diet.

4. The client is a candidate for the least restrictive environment.

Correct Answer: 2

Rationale 1: Axis II contains the personality disorders usually diagnosed in adults, and developmental disorders including mental retardation, diagnosed in children and adolescents. Axis II is also used to report maladaptive personality traits. Information about diet and the level of care needed are written in the admission orders, not the multiaxial diagnosis.

Rationale 2: Axis II contains the personality disorders usually diagnosed in adults, and developmental disorders including mental retardation, diagnosed in children and adolescents. Axis II is also used to report maladaptive personality traits. Information about diet and the level of care needed are written in the admission orders, not the multiaxial diagnosis.

Rationale 3: Axis II contains the personality disorders usually diagnosed in adults, and developmental disorders including mental retardation, diagnosed in children and adolescents. Axis II is also used to report maladaptive personality traits. Information about diet and the level of care needed are written in the admission orders, not the multiaxial diagnosis.

Rationale 4: Axis II contains the personality disorders usually diagnosed in adults, and developmental disorders including mental retardation, diagnosed in children and adolescents. Axis II is also used to report maladaptive personality traits. Information about diet and the level of care needed are written in the admission orders, not the multiaxial diagnosis.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: Explain the importance of each of the five axes of the DSM multiaxial system to the overall assessment of clients and their families.

Question 14

Type: MCSA

A female client disclosed to the nurse that she is in an abusive situation. This information will be used to contribute to:

1. Axis IV.

2. Axis III.

3. Nothing, since this is confidential information and should not be shared.

Correct Answer: 1

Rationale 1: Axis IV is used to identify psychosocial problems that may affect the diagnosis and treatment of mental disorders. Clinicians use Axis III too.

Rationale 2: Axis IV is used to identify psychosocial problems that may affect the diagnosis and treatment of mental disorders. Clinicians use Axis III too.

Rationale 3: Axis IV is used to identify psychosocial problems that may affect the diagnosis and treatment of mental disorders. Clinicians use Axis III too.

Rationale 4: Axis IV is used to identify psychosocial problems that may affect the diagnosis and treatment of mental disorders. Clinicians use Axis III too.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Explain the importance of each of the five axes of the DSM multiaxial system to the overall assessment of clients and their families.

Question 15

Type: MCSA

The nurse on the inpatient unit is reviewing the record of a client admitted the previous day, and notes the client has an Axis I diagnosis. What inferences can the nurse make about the client?

1. The client has a clinical psychiatric disorder.

2. The client is in need of immediate medical attention.

3. The client has a chronic condition.

4. The client lacks a support system.

Correct Answer: 1

Rationale 1: Axis I provides information regarding major mental disorders, as well as developmental and learning disorders. Axis I does not provide information about support systems, chronic conditions, or indicate if the client is in need of immediate medical attention.

Rationale 2: Axis I provides information regarding major mental disorders, as well as developmental and learning disorders. Axis I does not provide information about support systems, chronic conditions, or indicate if the client is in need of immediate medical attention.

Rationale 3: Axis I provides information regarding major mental disorders, as well as developmental and learning disorders. Axis I does not provide information about support systems, chronic conditions, or indicate if the client is in need of immediate medical attention.

Rationale 4: Axis I provides information regarding major mental disorders, as well as developmental and learning disorders. Axis I does not provide information about support systems, chronic conditions, or indicate if the client is in need of immediate medical attention.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Explain the importance of each of the five axes of the DSM multiaxial system to the overall assessment of clients and their families.

Question 16

Type: MCMA

How might the nurse make use of the information contained in a clients multiaxial diagnosis?

Standard Text: Select all that apply.

1. To address physiological problems

2. To plan client-centered interventions

3. To communicate client needs

4. To assess client strengths

5. To identify nursing diagnoses

Correct Answer: 1,2,3,4,5

Rationale 1: The diagnosis and information contained in Axis I-IV can be utilized at all phases of the nursing process in developing and delivering client-centered nursing care.

Rationale 2: The diagnosis and information contained in Axis IIV can be utilized at all phases of the nursing process in developing and delivering client-centered nursing care.

Rationale 3: The diagnosis and information contained in Axis IIV can be utilized at all phases of the nursing process in developing and delivering client-centered nursing care.

Rationale 4: The diagnosis and information contained in Axis IIV can be utilized at all phases of the nursing process in developing and delivering client-centered nursing care.

Rationale 5: The diagnosis and information contained in Axis IIV can be utilized at all phases of the nursing process in developing and delivering client-centered nursing care.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: Explain the importance of each of the five axes of the DSM multiaxial system to the overall assessment of clients and their families.

Question 17

Type: MCSA

A client is admitted with the following diagnosis:

Axis I: 300.01 Panic disorder without agoraphobia

Axis II: 301.83 Borderline personality disorder

Axis III: No diagnosis

Axis IV: Unemployment

What conclusions can the nurse make relative to the clients Axis III information?

1. This client has problems with environment, but they are not related to mental disorder.

2. The clients environment has not been evaluated.

3. The clients health status has not been evaluated.

4. The client has no diagnosed physiological health problems relevant to mental disorder at the time of admission.

Correct Answer: 4

Rationale 1: Clinicians use Axis III to record physical disorders and medical conditions that must be taken into account in planning treatment at the time of admission. Axis IV is used to identify problems or issues of a psychosocial and environmental nature.

Rationale 2: Clinicians use Axis III to record physical disorders and medical conditions that must be taken into account in planning treatment at the time of admission. Axis IV is used to identify problems or issues of a psychosocial and environmental nature.

Rationale 3: Clinicians use Axis III to record physical disorders and medical conditions that must be taken into account in planning treatment at the time of admission. Axis IV is used to identify problems or issues of a psychosocial and environmental nature.

Rationale 4: Clinicians use Axis III to record physical disorders and medical conditions that must be taken into account in planning treatment at the time of admission. Axis IV is used to identify problems or issues of a psychosocial and environmental nature.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Explain the importance of each of the five axes of the DSM multiaxial system to the overall assessment of clients and their families.

Question 18

Type: MCSA

The school nurse, who must be familiar with mental health issues, will find child clinical disorders classified under:

1. Axis II.

2. Axis I.

3. Axis X.

4. Axis VII.

Correct Answer: 2

Rationale 1: Axis I includes all of the Adult and Child Clinical Disorders. Axis II contains the personality disorders, usually diagnosed in adults, and developmental disorders including mental retardation, diagnosed in children and adolescents. There is no Axis VII or X in the multiaxial system.

Rationale 2: Axis I includes all of the Adult and Child Clinical Disorders. Axis II contains the personality disorders, usually diagnosed in adults, and developmental disorders including mental retardation, diagnosed in children and adolescents. There is no Axis VII or X in the multiaxial system.

Rationale 3: Axis I includes all of the Adult and Child Clinical Disorders. Axis II contains the personality disorders, usually diagnosed in adults, and developmental disorders including mental retardation, diagnosed in children and adolescents. There is no Axis VII or X in the multiaxial system.

Rationale 4: Axis I includes all of the Adult and Child Clinical Disorders. Axis II contains the personality disorders, usually diagnosed in adults, and developmental disorders including mental retardation, diagnosed in children and adolescents. There is no Axis VII or X in the multiaxial system.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Explain the importance of each of the five axes of the DSM multiaxial system to the overall assessment of clients and their families.

Question 19

Type: MCSA

After interviewing a client for admission, the nurse gives the client a score of 50 on the Global Assessment of Functioning Scale (GAF). The nurse selected this score based on the clients level of functioning:

1. Since being given a psychiatric diagnosis.

2. Within the past week.

3. Since beginning the psychotropic medication.

4. Within the past year.

Correct Answer: 2

Rationale 1: The GAF Scale rates the clients lowest level of functioning within the previous seven days. The GAF Scale does not include impairment due to physical or environmental limitations.

Rationale 2: The GAF Scale rates the clients lowest level of functioning within the previous seven days. The GAF Scale does not include impairment due to physical or environmental limitations.

Rationale 3: The GAF Scale rates the clients lowest level of functioning within the previous seven days. The GAF Scale does not include impairment due to physical or environmental limitations.

Rationale 4: The GAF Scale rates the clients lowest level of functioning within the previous seven days. The GAF Scale does not include impairment due to physical or environmental limitations.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Incorporate the result of the GAF scale in a nursing care plan for a client with mental disorder.

Question 20

Type: MCSA

Select the priority nursing diagnosis for a client with a Global Assessment of Functioning (GAF) score of 10.

1. Risk for Impaired Social Interaction

2. Risk for Injury

3. Knowledge Deficit

4. Risk for Communication Deficit

Correct Answer: 2

Rationale 1: The client with a GAF of 10 manifests persistent danger of severely hurting self or others. In this case, the nurse wants to prevent the occurrence of an injury; therefore, the risk for injury supersedes the risk for impaired social interaction, risk for communication deficit, and knowledge deficit.

Rationale 2: The client with a GAF of 10 manifests persistent danger of severely hurting self or others. In this case, the nurse wants to prevent the occurrence of an injury; therefore, the risk for injury supersedes the risk for impaired social interaction, risk for communication deficit, and knowledge deficit.

Rationale 3: The client with a GAF of 10 manifests persistent danger of severely hurting self or others. In this case, the nurse wants to prevent the occurrence of an injury; therefore, the risk for injury supersedes the risk for impaired social interaction, risk for communication deficit, and knowledge deficit.

Rationale 4: The client with a GAF of 10 manifests persistent danger of severely hurting self or others. In this case, the nurse wants to prevent the occurrence of an injury; therefore, the risk for injury supersedes the risk for impaired social interaction, risk for communication deficit, and knowledge deficit.

Global Rationale:

Cognitive Level: Evaluating

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: Incorporate the result of the GAF scale in a nursing care plan for a client with mental disorder.

Question 21

Type: MCSA

The psychiatric home health nurse is evaluating whether a clients level of functioning has improved since starting the prescribed psychotropic medication. What evidence does the nurse look for?

1. There is no change in the GAF score.

2. There is a significant decrease (by 10 or more points) in the clients GAF score.

3. The client no longer qualifies for a GAF score.

4. There is an increase in the clients GAF score.

Correct Answer: 4

Rationale 1: The range of the Global Assessment of Functioning (GAF) score is 0100 with 0 indicating there is inadequate information and 100 indicating the client has superior functioning in a wide range of activities, lifes problems never seem to get out of hand, the client is sought out by others because of his or her many positive qualities, and the client is having no symptoms. When evaluating the GAF score, generally an increase over the score at admission indicates there is some improvement in the clients level of functioning.

Rationale 2: The range of the Global Assessment of Functioning (GAF) score is 0100 with 0 indicating there is inadequate information and 100 indicating the client has superior functioning in a wide range of activities, lifes problems never seem to get out of hand, the client is sought out by others because of his or her many positive qualities, and the client is having no symptoms. When evaluating the GAF score, generally an increase over the score at admission indicates there is some improvement in the clients level of functioning.

Rationale 3: The range of the Global Assessment of Functioning (GAF) score is 0100 with 0 indicating there is inadequate information and 100 indicating the client has superior functioning in a wide range of activities, lifes problems never seem to get out of hand, the client is sought out by others because of his or her many positive qualities, and the client is having no symptoms. When evaluating the GAF score, generally an increase over the score at admission indicates there is some improvement in the clients level of functioning.

Rationale 4: The range of the Global Assessment of Functioning (GAF) score is 0100 with 0 indicating there is inadequate information and 100 indicating the client has superior functioning in a wide range of activities, lifes problems never seem to get out of hand, the client is sought out by others because of his or her many positive qualities, and the client is having no symptoms. When evaluating the GAF score, generally an increase over the score at admission indicates there is some improvement in the clients level of functioning.

Chapter 4. The Initial Contact and Maintaining the Frame

Question 1

Type: MCSA

The nurse is establishing a therapeutic alliance with a new client. Which of the following behaviors would enhance the development of a therapeutic one-to-one relationship?

1. Specifically defining emotional and social goals for the client

2. Eagerly encouraging the client to communicate on a superficial level

3. Instinctively sharing personal experiences with the client