Essentials of Psychiatric Mental Health Nursing Concepts of Care in Evidence-Based Practice

Essentials of Psychiatric Mental Health Nursing

Concepts of Care in Evidence-Based Practice
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Chapter 7: The Nursing Process in Psychiatric/Mental Health Nursing

Multiple Choice

1. Which statement is most accurate regarding the assessment of clients diagnosed with
psychiatric problems?
1. Medical history is of little significance and can be eliminated from the nursing assessment.
2. Assessment provides a holistic view of the client, including biopsychosocial aspects.
3. Comprehensive assessments can be performed only by advanced practice nurses.
4. Psychosocial evaluations are gained by subjective reports rather than objective observations.

ANS: 2
Rationale: The assessment of clients diagnosed with psychiatric problems should provide a
holistic view of the client. A thorough assessment involves collecting and analyzing data from
the client, significant others, and health-care providers, which may include the following
dimensions: physical, psychological, sociocultural, spiritual, cognitive, functional abilities,
developmental, economic, and lifestyle.

Cognitive Level: Application

Integrated Process: Assessment

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

1. Nursing interventions are independent from the treatment team’s goals.
2. Nursing interventions are solely directed by written physician orders.
3. Nursing interventions occur independently but in concert with overall treatment team goals.
4. Nursing interventions are standardized by policies and procedures.

ANS: 3
Rationale: The nurse should understand that nursing interventions occur independently but in
concert with overall treatment goals. Nursing interventions should be developed and
implemented in collaboration with other health-care professionals involved in the client’s care.

Cognitive Level: Application

Integrated Process: Implementation
3. Within the nurse’s scope of practice, which function is exclusive to the advanced practice
psychiatric nurse?
1. Teaching about the side effects of neuroleptic medications
2. Using psychotherapy to improve mental health status
3. Using milieu therapy to structure a therapeutic environment
4. Providing case management to coordinate continuity of health services

ANS: 2
Rationale: The advanced practice psychiatric nurse is authorized to use psychotherapy to
improve mental health. This includes individual, couples, group, and family psychotherapy.
Education, case management, and milieu therapy can be provided by registered psychiatric
mental health nurses.

Cognitive Level: Application

Integrated Process: Implementation

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

1. SOAPIE
2. APIE
3. DAR
4. PQRST

ANS: 1
Rationale: The acronym SOAPIE represents problem-oriented charting, which reflects the
subjective, objective, assessment, plan, implementation, and evaluation format. Used in nursing,
nursing diagnoses (problems) are identified on a written plan of care, with appropriate nursing
interventions described for each.

Cognitive Level: Comprehension

Integrated Process: Implementation

5. Which tool would be appropriate for a nurse to use when assessing mental acuity prior to and
immediately following electroconvulsive therapy (ECT)?
1. CIWA scale
2. GGT
3. MMSE
4. CAPS scale

ANS: 3
Rationale: The MMSE, or mini mental status exam, would be the appropriate tool to use to
assess the mental acuity of a client prior to and immediately following ECT. The CIWA scale, or
clinical institute withdrawal assessment scale, would be used to assess withdraw from substances
such as alcohol. The CAPS refers to the clinician-administered PTSD scale and would be used to
assess signs and symptoms of PTSD. The GGT test is a blood test used to assess gamma-
glutamyl transferase levels, which may be an indication of alcoholism.

Cognitive Level: Application

Integrated Process: Assessment

6. What is being assessed when a nurse asks a client to identify name, date, residential address,
and situation?
1. Mood
2. Perception
3. Orientation
4. Affect

ANS: 3
Rationale: The nurse should ask the client to identify name, date, residential address, and
situation to assess the client’s orientation. Assessment of the client’s orientation to reality is part
of a mental status evaluation.

Cognitive Level: Application

Integrated Process: Assessment

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

1. It enables the nurse to modify behaviors related to personality disorders.
2. It enables the nurse to make sound clinical judgments and plan appropriate care.
3. It enables the nurse to prescribe the appropriate medications.
4. It enables the nurse to assign the appropriate Axis I diagnosis.

ANS: 2
Rationale: The purpose of gathering client information is to enable the nurse to make sound
clinical judgments and plan appropriate care. The nurse should complete a thorough assessment
of the client, including information collected from the client, significant others, and health-care
providers.

Cognitive Level: Application

Integrated Process: Assessment
8. A nurse on an inpatient psychiatric unit implements care by scheduling client activities,
interacting with clients, and maintaining a safe therapeutic environment. These actions reflect
which role of the nurse?
1. Health teacher
2. Case manager
3. Milieu manager
4. Psychotherapist

ANS: 3
Rationale: The milieu manager implements care by scheduling client activities, interacting with
clients, and maintaining a safe therapeutic environment. Health teaching involves promoting
health in a safe environment. Case management is used to organize client care so that outcomes
are achieved. Psychotherapy involves conducting individual, couples, group, and family
counseling.

Cognitive Level: Application

Integrated Process: Implementation

9. The following outcome was developed for a client: “Client will list five personal strengths by
the end of day one.” Which correctly written nursing diagnostic statement most likely generated
the development of this outcome?
1. Altered self-esteem R/T years of emotional abuse AEB self-deprecating statements
2. Self-care deficit R/T altered thought process
3. Disturbed body image R/T major depressive disorder AEB mood rating of 2/10
4. Risk for disturbed self-concept R/T hopelessness AEB suicide attempt

ANS: 1
Rationale: The nurse should determine that altered self-esteem and self-deprecating statements
would generate the outcome to list personal strengths by the end of day one. Self-care deficit,
disturbed body image, and risk for disturbed self-concept would generate specific outcomes in
accordance with specific needs and goals. The self-care deficit and risk for disturbed self-concept
nursing diagnoses are incorrectly written.

Cognitive Level: Application

Integrated Process: Diagnosis

10. How should a nurse prioritize nursing diagnoses?

1. By the established goal of care
2. By the life-threatening potential
3. By the physician’s priority of care
4. By the client’s preference
ANS: 2
Rationale: The nurse should prioritize nursing diagnoses related to their life-threatening
potential. Safety is always the nurse’s first priority.

Cognitive Level: Analysis

Integrated Process: Diagnosis

11. A client has a nursing diagnosis of Insomnia R/T paranoid thinking AEB MNA, DFA, and
daytime napping. Which is a correctly written and appropriate outcome for this client?
1. The client will avoid daytime napping and attend all groups.
2. The client will exercise, as needed, before bedtime.
3. The client will sleep seven uninterrupted hours by day four of hospitalization.
4. The client’s sleep habits will improve during hospitalization.

ANS: 3
Rationale: The outcome “The client will sleep seven uninterrupted hours by day four of
hospitalization” is accurately written and an appropriate outcome for a client diagnosed with
insomnia. Nursing outcomes should be derived from the diagnosis, measurable, and include a
time estimate for attainment. The outcome must also be realistic for the client’s capabilities.

Cognitive Level: Analysis

Integrated Process: Planning

12. The following NANDA-I nursing diagnostic stem was developed for a client on an inpatient
unit: Risk for injury. What assessment data most likely led to the development of this problem
statement?
1. The client is receiving ECT and is diagnosed with Parkinsonism.
2. The client has a history of four suicide attempts in adolescence.
3. The client expresses hopelessness and helplessness and isolates self.
4. The client has disorganized thought processes and delusional thinking.

ANS: 1
Rationale: The nurse should identify that a client receiving ECT and who is diagnosed with
Parkinsonism is at risk for injury. History of suicide, hopelessness, and disorganized thoughts
would not lead the nurse to formulate a nursing diagnostic stem of Risk for injury.

Cognitive Level: Application

Integrated Process: Assessment
13. A student nurse asks an instructor how best to develop nursing outcomes for clients. Which
response by the instructor most accurately answers the student’s question?
1. “You can use NIC, a standardized reference for nursing outcomes.”
2. “Look at your client’s problems and set a realistic, achievable goal.”
3. “With client collaboration, outcomes should be based on client problems.”
4. “Copy your standard outcomes from a nursing care plan textbook.”

ANS: 3
Rationale: Client outcomes are most realistic and achievable when there is collaboration among
the interdisciplinary team members, the client, and significant others.

Cognitive Level: Application

Integrated Process: Planning

14. A client diagnosed with schizophrenia is exhibiting nonverbal behaviors indicating that the
client is hearing things that others do not. Which nursing diagnosis, which was recently removed
from the NANDA-I list, still accurately reflects this client’s problem?
1. Disturbed thought processes
2. Disturbed sensory perception
3. Anxiety
4. Chronic confusion

ANS: 2
Rationale: The nursing diagnosis disturbed sensory perception accurately reflects the client’s
symptoms of hearing things that others do not. The nursing diagnosis describes the client’s
condition and facilitates the prescription of interventions.

Cognitive Level: Application

Integrated Process: Diagnosis

Multiple Response
15. Which of the following nursing interventions fall within the standards of psychiatric–mental
health clinical nursing practice for a nurse generalist? (Select all that apply.)
1. Assist the client to perform activities of daily living.
2. Consult with other clinicians to provide services for clients and effect system change.
3. Encourage the client to discuss triggers for relapse.
4. Use prescriptive authority in accordance with state and federal laws.
5. Educate the family about signs and symptoms of alcohol dependence and withdrawal.

ANS: 1, 3, 5
Rationale: Assisting the client to perform daily living activities, encouraging the client to discuss
triggers, and educating the family are nursing interventions that fall within the standards of
psychiatric clinical nursing practice for a nurse generalist. Psychiatric–mental health advanced
practice registered nurses can consult with other clinicians and use prescriptive authority.

Cognitive Level: Application

Integrated Process: Implementation

16. Which of the following characteristics of accurately developed client outcomes should a
nurse identify? (Select all that apply.)
1. Client outcomes are specifically formulated by nurses.
2. Client outcomes are not restricted by time frames.
3. Client outcomes are specific and measurable.
4. Client outcomes are realistically based on client capability.
5. Client outcomes are formally approved by the psychiatrist.

ANS: 3, 4
Rationale: The nurse should identify that client outcomes should be specific, measurable, and
realistically based on client capability. Outcomes should be derived from the diagnosis and
should include a time estimate for attainment. Outcomes are most effective when formulated
cooperatively by the interdisciplinary team members, the client, and significant others.

Cognitive Level: Application

Integrated Process: Planning

Ordered Response

17. Number the following nursing interventions as they would proceed through the steps of the
nursing process.
________ Determine if an antianxiety medication is decreasing a client’s stress.
________ Measure a client’s vital signs and review past history.
Essentials of Psychiatric Mental Health Nursing Concepts of Care in Evidence-Based Practice

________ Encourage deep breathing and teach relaxation techniques.

________ Aim, with client collaboration, for a seven-hour night’s sleep.
________ Recognize and document the client’s problem.

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

Rationale:
1. Measuring a client’s vital signs and reviewing past history is a nursing intervention that occurs
in the assessment step of the nursing process.
2. Recognizing and documenting the client’s problem occurs in the nursing diagnosis step.
3. Setting a goal with client collaboration, for a seven-hour night’s sleep occurs in the planning
step.
4. Encouraging deep breathing and teaching relaxation techniques occur in the implementation
step.
5. Determining if an antianxiety medication is decreasing a client’s stress occurs in the
evaluation step.

Cognitive Level: Analysis

Integrated Process: Implementation

Fill-in-the-Blank

18. A _________________ __________________ provides the basis for selection of nursing

interventions to achieve outcomes for which the nurse has accountability.

ANS: nursing diagnosis

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

Cognitive Level: Application

Integrated Process: Diagnosis

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