Essentialsof psychiatric Mental Health Nursing 7e TownSend TB-The Nursing Process

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. ____ 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. ____ 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 ____ 4. The nurse should recognize which acronym as representing problem-oriented charting? 1. SOAPIE 2. APIE 3. DAR 4. PQRST ____ 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 ____ 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 ____ 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. ____ 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 ____ 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 ____ 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 ____ 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. ____ 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. ____ 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.” ____ 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 Multiple Response Identify one or more choices that best complete the statement or answer the question. ____ 15. 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. Other 16. 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. ________ 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. Completion Complete each statement. 17. A _________________ __________________ provides the basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability. Chapter 7: The Nursing Process in Psychiatric/Mental Health Nursing Answer Section MULTIPLE CHOICE 1. ANS: 2 Chapter: Chapter 7, The Nursing Process in Psychiatric/Mental Health Nursing Objective: Identify six steps of the nursing process and describe nursing actions associated with each. Page: 148 Heading: The Nursing Process Assessment Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Easy Feedback 1 Medical history is significant and should not be eliminated from the nursing assessment. 2 The assessment of clients diagnosed with psychiatric problems should provide a holistic view of the client. 3 Assessments can be completed by a variety of health-care providers. 4 The nurse should gather subject and objective information. PTS: 1 CON: Patient-Centered Care 2. ANS: 3 Chapter: Chapter 7, The Nursing Process in Psychiatric/Mental Health Nursing Objective: Identify six steps of the nursing process and describe nursing actions associated with each. Page: 156 Heading: Standards of Practice Nursing Interventions Classification (NIC) Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 Nursing interventions should be developed and implemented in collaboration with other health-care professionals involved in the client’s care. 2 Nursing interventions are not solely directed by written physician orders. 3 The nurse should understand that nursing interventions occur independently but in concert with overall treatment goals. 4 Nursing interventions are created in conjunction with standardized by policies and procedures. PTS: 1 CON: Patient-Centered Care 3. ANS: 2 Chapter: Chapter 7, The Nursing Process in Psychiatric/Mental Health Nursing Objective: Identify six steps of the nursing process and describe nursing actions associated with each. Page: 156 Heading: The Nursing Process Standard 5D. Prescriptive Authority and Treatment Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 Teaching about the side effects of neuroleptic medications can be completed by Registered Nurses. 2 The advanced practice psychiatric nurse is authorized to use psychotherapy to improve mental health. This includes individual, couples, group, and family psychotherapy. 3 Using milieu therapy to structure a therapeutic environment can be completed by Registered Nurses. 4 Providing case management to coordinate continuity of health services can be completed by Registered Nurses. PTS: 1 CON: Patient-Centered Care 4. ANS: 1 Chapter: Chapter 7, The Nursing Process in Psychiatric/Mental Health Nursing Objective: Document client care that validates use of the nursing process. Page: 162 Heading: Documentation of the Nursing Process Problem-oriented Recording Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Comprehension (Understanding) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 The acronym SOAPIE represents problem-oriented charting, which reflects the subjective, objective, assessment, plan, implementation, and evaluation format. 2 APIE does not represent problem-oriented charting. 3 DAR does not represent problem-oriented charting. 4 PQRST does not represent problem-oriented charting. PTS: 1 CON: Patient-Centered Care 5. ANS: 3 Chapter: Chapter 7, The Nursing Process in Psychiatric/Mental Health Nursing Objective: Identify six steps of the nursing process and describe nursing actions associated with each. Page: 147 Heading: The Nursing Process Assessment Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 The CIWA scale, or clinical institute withdrawal assessment scale, would be used to assess withdrawal from substances such as alcohol. 2 The GGT test is a blood test used to assess gamma-glutamyl transferase levels, which may be an indication of alcoholism. 3 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. 4 The CAPS refers to the clinician-administered PTSD scale and would be used to assess signs and symptoms of PTSD. PTS: 1 CON: Patient-Centered Care 6. ANS: 3 Chapter: Chapter 7, The Nursing Process in Psychiatric/Mental Health Nursing Objective: Apply the six steps of the nursing process in the care of a client within the psychiatric setting. Page: 155 Heading: Table 7-1 Brief Mental Status Evaluation Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 These questions do not assess mood. 2 These questions do not assess perception. 3 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. 4 These questions do not assess affect. PTS: 1 CON: Patient-Centered Care 7. ANS: 2 Chapter: Chapter 7, The Nursing Process in Psychiatric/Mental Health Nursing Objective: Identify six steps of the nursing process and describe nursing actions associated with each. Page: 156 Heading: The Nursing Process Planning Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 Modifying behaviors can occur after the nurse completes a thorough assessment. 2 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. 3 After completing a thorough assessment, the nurse can prescribe the appropriate medications. 4 After completing a thorough assessment, the nurse can assign the appropriate Axis I diagnosis. PTS: 1 CON: Patient-Centered Care 8. ANS: 3 Chapter: Chapter 7 The Nursing Process in Psychiatric/Mental Health Nursing Objective: Apply the six steps of the nursing process in the care of a client within the psychiatric setting. Page: 156 Heading: The Nursing Process Standard 5F. Milieu Therapy Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 Health teaching involves promoting health in a safe environment. 2 Case management is used to organize client care so that outcomes are achieved. 3 The milieu manager implements care by scheduling client activities, interacting with clients, and maintaining a safe therapeutic environment. 4 Psychotherapy involves conducting individual, couples, group, and family counseling. PTS: 1 CON: Patient-Centered Care 9. ANS: 1 Chapter: Chapter 7, The Nursing Process in Psychiatric/Mental Health Nursing Objective: Apply the six steps of the nursing process in the care of a client within the psychiatric setting. Page: 159 Heading: Applying the Nursing Process in the Psychiatric Setting Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 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. 2 The self-care deficit nursing diagnoses is incorrectly written. 3 Disturbed body image would generate specific outcomes in accordance with specific needs and goals. 4 The risk for disturbed self-concept nursing diagnoses is incorrectly written. PTS: 1 CON: Patient-Centered Care 10. ANS: 2 Chapter: Chapter 7, The Nursing Process in Psychiatric/Mental Health Nursing Objective: Apply the six steps of the nursing process in the care of a client within the psychiatric setting. Page: 159 Heading: Applying the Nursing Process in the Psychiatric Setting Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 Client care goals can be met after safety has been established. 2 The nurse should prioritize nursing diagnoses related to their life-threatening potential. Safety is always the nurse’s first priority. 3 The physician’s priority of care can be met after safety has been established. 4 The client can choose a goal as a priority after safety has been established. PTS: 1 CON: Patient-Centered Care 11. ANS: 3 Chapter: Chapter 7, The Nursing Process in Psychiatric/Mental Health Nursing Objective: Apply the six steps of the nursing process in the care of a client within the psychiatric setting. Page: 159 Heading: Applying the Nursing Process in the Psychiatric Setting Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 Avoiding naps and attending all groups may not be realistic for this client. 2 Exercising before bedtime will not help the client overcome insomnia. 3 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. 4 This diagnosis is not specific towards the client’s needs. PTS: 1 CON: Patient-Centered Care 12. ANS: 1 Chapter: Chapter 7, The Nursing Process in Psychiatric/Mental Health Nursing Objective: Discuss the list of nursing diagnoses approved by NANDA International for clinical use and testing. Page: 155 Heading: The Nursing Process Standard 2. Diagnosis Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 The nurse should identify that a client receiving ECT and who is diagnosed with Parkinsonism is at risk for injury. 2 History of suicide, hopelessness, and disorganized thoughts would not lead the nurse to formulate a nursing diagnostic stem of risk for injury. 3 History of hopelessness and helplessness would not lead the nurse to formulate a nursing diagnostic stem of risk for injury. 4 History of disorganized thoughts and delusional thinking would not lead the nurse to formulate a nursing diagnostic stem of risk for injury. PTS: 1 CON: Patient-Centered Care 13. ANS: 3 Chapter: Chapter 7, The Nursing Process in Psychiatric/Mental Health Nursing Objective: Discuss the list of nursing diagnoses approved by NANDA International for clinical use and testing. Page: 155 Heading: The Nursing Process Standard 2. Diagnosis Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 Using NIC does not help develop outcomes specific for the client. 2 This option is helpful, but the most attainable goals are set with collaboration. 3 Client outcomes are most realistic and achievable when there is collaboration among the interdisciplinary team members, the client, and significant others. 4 Goals should be personalized for each client. PTS: 1 CON: Patient-Centered Care 14. ANS: 2 Chapter: Chapter 7, The Nursing Process in Psychiatric/Mental Health Nursing Objective: Discuss the list of nursing diagnoses approved by NANDA International for clinical use and testing. Page: 161 Heading: Applying the Nursing Process in the Psychiatric Setting Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 The nursing diagnosis, disturbed thought processes, does not accurately reflect the client’s problem. 2 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. 3 The nursing diagnosis, anxiety, does not accurately reflect the client’s problem. 4 The nursing diagnosis, chronic confusion, does not accurately reflect the client’s problem. PTS: 1 CON: Patient-Centered Care MULTIPLE RESPONSE 15. ANS: 3, 4 Chapter: Chapter 7, The Nursing Process in Psychiatric/Mental Health Nursing Objective: Identify six steps of the nursing process and describe nursing actions associated with each. Page: 155 Heading: Standard 3. Outcomes Identification Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1. Outcomes are most effective when formulated cooperatively by the interdisciplinary team members, the client, and significant others. 2. Outcomes should be given a time frame. 3. The nurse should identify that client outcomes should be specific and measurable. 4. The nurse should identify that client outcomes should be based on client capability. 4. 5. Outcomes do not need to be approved by a psychiatrist. PTS: 1 CON: Patient-Centered Care ORDERED RESPONSE 16. ANS: 2, 5, 4, 3, 1. Chapter: Chapter 7, The Nursing Process in Psychiatric/Mental Health Nursing Objective: Identify six steps of the nursing process and describe nursing actions associated with each. Page: 147 Heading: The Nursing Process Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Moderate Feedback: Measuring a client’s vital signs and reviewing past history is a nursing intervention that occurs in the assessment step of the nursing process. Recognizing and documenting the client’s problem occurs in the nursing diagnosis step. Setting a goal with client collaboration, for a seven-hour night’s sleep occurs in the planning step. Encouraging deep breathing and teaching relaxation techniques occurs in the implementation step. Determining if an antianxiety medication is decreasing a client’s stress occurs in the evaluation step. PTS: 1 CON: Patient-Centered Care COMPLETION 17. ANS: nursing diagnosis Chapter: Chapter 7, The Nursing Process in Psychiatric/Mental Health Nursing Objective: Identify six steps of the nursing process and describe nursing actions associated with each. Page: 154 Heading: Core Concept Integrated Processes: Nursing Process Cognitive Level: Application [Applying] Client Need: Psychosocial Integrity Concept: Patient-Centered Care Difficulty: Moderate Feedback: 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. PTS: 1 CON: Patient-Centered Car