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Test Bank for Keltner’s Psychiatric Nursing, 9th Edition by Debbie Steele |Chapter 1-36 | All Chapters
Test Bank for Keltner’s Psychiatric Nursing, 9th Edition by Debbie Steele |Chapter 1-36 | All Chapters
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Test Bank for Keltner’s PsychiatricNursing, 9th Edition by Debbie Steele
|Chapter 1-36 | All Chapters
Chapter 01: Me, Meds, Milieu
Steele: Keltner’s Psychiatric Nursing, 9th Edition
MULTIPLE CHOICE
1. A newly licensed nurse asks a nursing recruiter for a description of nursing practice in the
psychiatric setting. What is the nurse recruiter‘s best response?
a. ―The nurse primarily serves in a supportive role to members of the health care
delivery team.‖
b. ―The multidisciplinary approach eliminates the need to clearly define the
responsibilities of nursing in such a setting.‖
c. ―Nursing actions are identified by the institution that distinguishes nursing from
other mental health professions.‖
d. ―Nursing offers unique contributions to the psychotherapeutic management of
psychiatric patients.‖
ANS: D
Professional role overlap cannot be denied; however, nursing is unique in its focus on and
application of psychotherapeutic management. Neither the facility nor the multidisciplinary
team define the professional responsibilities of its members but rather utilizes their unique
skills to provide holistic care. Ideally, all team members support each other and have
functions within the team.
DIF: Cognitive level: Analyzing TOP: Nursing process: Implementation
MSC: Client Needs: Safe, Effective Care Environment
2. Which component of the nursing process will the nurse focus upon to address the
responsibility to match individual patient needs with appropriate services?
a. Planning
b. Evaluation
c. Assessment
d. Implementation
ANS: C
Proper assessment is critical for being able to determine the appropriate level of services that
will provide optimal care while considering patient input and at the lowest cost. Planning and
implementation utilizes the assessment data to identify and execute actions (treatment plan)
that will provide appropriate care. Evaluation validates the effectiveness of the treatment plan.
DIF: Cognitive level: Applying TOP: Nursing process: Assessment
MSC: Client Needs: Safe, Effective Care Environment
3. An adult diagnosed with paranoid schizophrenia frequently experiences auditory
hallucinations and walks about the unit, muttering. Which nursing action demonstrates the
nurse‘s understanding of effective psychotherapeutic management of this client?
,a. Discussing the disease process of schizophrenia with the client and their domestic
partner
b. Minimizing contact between this patient and other patients to assure a stress-free
milieu
c. Administering PRN medication when first observing the evidence that the client
, may be hallucinating
d. Independently determining that behavior modification is appropriate to decrease
the client‘s paranoid thoughts
ANS: A
An understanding of psychopathology is the foundation on which the three components of
psychotherapeutic management rest; it facilitates therapeutic communication and provides a
basis for understanding psychopharmacology and milieu management. Minimizing contact
between the patient and others and administering PRN medication indiscriminately are
nontherapeutic interventions. Using behavior modification to decrease the frequency of
hallucinations would need to be incorporated into the plan of care by the care team.
DIF: Cognitive level: Applying TOP: Nursing process: Implementation
MSC: Client Needs: Safe, Effective Care Environment
4. An adult diagnosed with chronic depression is hospitalized after a suicide attempt. Which
intervention is critical in assuring long-term, effective client care as described by
psychotherapeutic management?
a. Involvement in group therapies
b. Focus of close supervision by the unit staff
c. Maintaining effective communication with support system
d. Frequently scheduled one-on-one time with nursing staff
ANS: D
A critical element of psychotherapeutic management is the presence of a therapeutic
nurse-patient relationship. One-on-one time with nursing staff will help in establishing this
connection. While the other options are appropriate and client centered, the nurse-client
relation is critical in the long-term delivery of quality effective care to this client.
DIF: Cognitive level: Applying TOP: Nursing process: Implementation
MSC: Client Needs: Psychosocial Integrity
5. A patient‘s haloperidol dosage was reduced 2 weeks ago to decrease side effects. What
assessment question demonstrates the nurse‘s understanding of the resulting needs of the
client?
a. ―Will you have any difficulty getting your prescription refilled?‖
b. ―Have you begun experiencing any forms of hallucinations?‖
c. ―What do you expect will occur since the dosage has been reduced?‖
d. ―What can I do to help you manage this reduction in haloperidol therapy?‖
ANS: B
It will be necessary for the nurse to assess for exacerbation of the patient‘s symptoms of
psychosis as well as for a lessening of side effects. Dosage decrease might lead to the return
or worsening of positive symptoms such as hallucinations and delusions, and negative
symptoms such as blunted affect, social withdrawal, and poor grooming. While the other
options may be appropriate assessment questions, they are not directed at the current needs of
the client which is the identification of emerging psychotic behaviors.
DIF: Cognitive level: Analyzing TOP: Nursing process: Assessment
MSC: Client Needs: Physiologic Integrity
,6. Which statement forms the foundation upon which a nurse should base the implementation of
psychotherapeutic management to the care of a patient with mental illness?
a. The nurse‘s role in client care is supported by the multidisciplinary team.
b. Omitting any one component will compromise the effectiveness of the treatment.
c. The most important element of psychotherapeutic management is drug therapy.
d. A therapeutic nurse-patient relationship is the most important aspect of treatment.
ANS: B
When one element is missing, treatment is usually compromised. No single element is more
important than the others; however, patients‘ needs govern the application of the components
and permit judicious use. The remaining options identify components of the
psychotherapeutic management process.
DIF: Cognitive level: Analyzing TOP: Nursing process: Analysis
MSC: Client Needs: Safe, Effective Care Environment
7. Which statement most accurately describes a nurse‘s role regarding psychopharmacology?
a. ―You will need to frequently make decisions regarding the administration of PRN
medications to help the client manage anger.‖
b. ―It‘s a nursing responsibility to adjust a medication dose to assure effective patient
responses.‖
c. ―Nurses administers medications while evaluating drug effectiveness is a medical
responsibility.‖
d. ―To best assure appropriate response, a patient‘s questions about drug therapy
should be referred to the psychiatrist.‖
ANS: A
Nursing assessment and analysis of data might suggest the need for PRN medication as
patient anxiety increases or psychotic symptoms become more acute. The nurse is the health
team member who makes this determination. Nurses are responsible for monitoring drug
effectiveness as well as administering medication. Nurses should assume responsibility for
teaching patients about the side effects of medications. Nurses cannot alter prescribed dosages
of medications unless they have prescriptive privileges.
DIF: Cognitive level: Analyzing TOP: Nursing process: Analysis
MSC: Client Needs: Safe, Effective Care Environment
8. When considering environmental aspects of milieu management, which intervention has the
highest priority for a client admitted after a failed suicide attempt?
a. Sending the client‘s new medication prescriptions to the pharmacy
b. Assigning a staff member to one-on-one observation of the client
c. Orienting the client to the milieu‘s public and private spaces
d. Having all potentially dangerous items removed from the client‘s belongings
ANS: B
Milieu management provides a proactive approach to care. Safety overrides all other
dimensions of the milieu. Initiation of suicide precautions are the priority for this client. All
the remaining options are appropriate but none protect the client from the risk of another
attempt to self-harm as effectively as one-on-one observation as part of suicide precautions.
DIF: Cognitive level: Analyzing TOP: Nursing process: Implementation
, MSC: Client Needs: Safe, Effective Care Environment
9. The implementation of which unit policy directed at milieu balance would reflect a need for
reconsideration on the part of the treatment team?
a. All clients will receive verbal and written information explaining unit rules.
b. Unit clients will engage in all unit activities to assure interaction with both staff
and other clients.
c. All clients will be uniformly expected to present themselves in a nonviolent
manner to both staff and other clients.
d. At times of unit stress, client will return to their rooms.
ANS: B
The situation described suggests a milieu in which patients have no time for planned
therapeutic encounters with staff; hence, it is a milieu lacking balance. The remaining options
address unit norms, limit setting, and environmental modifications that are reasonable and will
contribute to a therapeutic milieu.
DIF: Cognitive level: Evaluating TOP: Nursing process: Evaluation
MSC: Client Needs: Safe, Effective Care Environment
10. Which intervention should the nurse implement when focusing on communicating
therapeutically with a client?
a. Explaining to the client why they will need to ask for a razor
b. Providing the client with options to help achieve smoking cessation
c. Encouraging the client to identify personal stressors
d. Assuring the client that they can receive telephone call on the unit telephone
ANS: C
A nurse uses therapeutic communication techniques as part of the therapeutic nurse-patient
relationship. An example of such communication is providing the client with an opportunity
to safely identify personal stressors. The remaining options address safety, balance, and norms
associated with their care.
DIF: Cognitive level: Applying TOP: Nursing process: Implementation
MSC: Client Needs: Psychosocial Integrity
11. During the risk assessment phase of care for a psychiatric patient, what is the nurse‘s primary
goal?
a. Making an initial assessment
b. Confirming the patient‘s problem
c. Assessing potential dangerousness to self or others
d. Determining the level of supervision needed for the patient
ANS: C
Risk assessment involves looking at dangerousness to self or others, the degree of disability,
and whether or not the individual is acutely psychotic to determine the feasibility of
community-based care versus hospital-based care. Risk assessment usually follows the initial
assessment. Confirmation of the patient‘s problem is not part of the risk assessment protocol.
Arranging entry into the mental health system will follow risk assessment if the patient is
assessed as needing service.
DIF: Cognitive level: Applying TOP: Nursing process: Assessment
, MSC: Client Needs: Safe, Effective Care Environment
12. Risk assessment for a patient shows these findings: schizophrenia but not currently; not a
danger to self or others; lives in parents‘ home. Which decision regarding placement on the
continuum of care is appropriate?
a. Hospitalize the patient.
b. Discharge the patient from the system.
c. Refer the patient to outpatient services.
d. Refer the patient to self-help resources in the community.
ANS: C
Referral should be made to the least restrictive, most effective, and most cost-conscious
source of services. Because the patient is not a danger to self or others, hospitalization is not
needed. However, follow-up as an outpatient would be more appropriate than referral to a
self-help group, in which structure might be lacking, or discharge from the system.
DIF: Cognitive level: Applying TOP: Nursing process: Planning
MSC: Client Needs: Safe, Effective Care Environment
13. A patient tells the nurse, ―This medicine makes me feel weird. I don‘t think I should take it
anymore. Do you?‖ The most effective reply that the nurse could make is based on which
psychotherapeutic management model?
a. Psychopathology
b. Milieu management
c. Psychopharmacology
d. Therapeutic nurse-patient relationship
ANS: C
Concerns about medication voiced by patients require the nurse to have knowledge about
psychotherapeutic drugs to make helpful responses. The nurse-patient relationship component
is based on use of self. Milieu management is concerned with the environment of care.
Psychopathology provides foundational knowledge of mental disorders but would be less
relevant in framing a response to the patient than knowledge of psychopharmacology.
DIF: Cognitive level: Analyzing TOP: Nursing process: Implementation
MSC: Client Needs: Physiologic Integrity
14. A patient tells the nurse, ―This medication makes me feel weird. I don‘t think I should take it
anymore. Do you?‖ What is the nurse‘s best response?
a. ―I wonder why you think that.‖
b. ―Tell me how the medication makes you feel.‖
c. ―One must never stop taking medication.‖
d. ―You need to discuss this with your psychiatrist.‖
ANS: B
As part of the psychopharmacology component of psychotherapeutic management, the
responsibility of the nurse is to gather data about patients‘ responses to medication and to be
alert for side and adverse effects of the medication. The other responses are tangential to the
real issue.
DIF: Cognitive level: Applying TOP: Nursing process: Implementation
MSC: Client Needs: Physiologic Integrity
,15. The spouse of a patient with panic attacks tells the nurse, ―I am afraid my husband has a
permanent disorder and will have many hospitalizations in the future. I wonder how I will be
able to raise our children alone.‖ The nurse‘s reply should be based on which form of nursing
knowledge?
a. Psychopathology
b. Milieu management
c. Psychopharmacology
d. Nursing relationship therapy
ANS: A
An understanding of psychopathology will enable the nurse to communicate reassurance to
the spouse regarding the treatment of panic attacks in an outpatient setting. None of the other
options has psychotherapeutic knowledge of psychiatric disorders as its focus.
DIF: Cognitive level: Applying TOP: Nursing process: Implementation
MSC: Client Needs: Psychosocial Integrity
16. Which observation during morning rounds should receive a nurse‘s priority attention?
a. Breakfast is late being served.
b. A sink is leaking, leaving water on the bathroom floor.
c. The daily schedule has not been posted on the unit bulletin board.
d. A small group of patients is complaining that one patient turned down the TV
volume.
ANS: B
Safety is the component of therapeutic milieu management that takes priority over the other
components. A patient could be injured if he or she slipped and fell. The other problems do
not pose a threat to patient safety.
DIF: Cognitive level: Analyzing TOP: Nursing process: Planning
MSC: Client Needs: Safe, Effective Care Environment
17. A community mental health nurse assessing a person with a psychiatric disorder, should refer
this person to services based on which basic concept?
a. Focus on interventions is on the least costly initially.
b. Initial interventions are the least restrictive.
c. Initial interventions offer a form of psychoeducation.
d. Rapid symptom stabilization is the primary goal.
ANS: B
The concept of least restrictive treatment environment preserves individual rights to freedom.
Many patients are healthy enough to receive community-based treatment. Hospitalization is
reserved for short periods when patients are assessed as being a danger to self or others. Cost
is a consideration but is of lesser concern than safety. All facets of the continuum should offer
psychoeducation as needed by patients and families. Some aspects of the care continuum are
more concerned with a patient‘s need for symptom stabilization than others (e.g., hospitals
versus psychiatric rehabilitation programs). The outcome of symptom stabilization is not a
need for some patients, so it is not a correct answer.
DIF: Cognitive level: Analyzing TOP: Nursing process: Implementation
MSC: Client Needs: Safe, Effective Care Environment
,18. An acutely psychotic patient is restricted to an inpatient unit. This intervention demonstrates
that which milieu element has been adapted?
a. Norms
b. Balance
c. Therapy
d. Psychopathology
ANS: B
Balance refers to negotiating the line between dependence and independence. The more
psychotic the individual, the less independence he or she can usually handle safely. Unit
restriction with careful supervision by staff helps compensate for lack of patient judgment.
Norms refers to behavioral expectations for patients. Therapy is provided by
advanced-practice nurses or others with advanced education and so is not an element of milieu
management. Psychopathology is not considered an environmental element.
DIF: Cognitive level: Analyzing TOP: Nursing process: Implementation
MSC: Client Needs: Safe, Effective Care Environment
19. An individual diagnosed with schizophrenia has a history of medication nonadherence. When
inpatient psychiatric care is not indicated, which service is the preferred referral?
a. Primary care
b. Outpatient counseling
c. Apartment residential living
d. A group home with 24-hour supervision
ANS: D
Although inpatient hospitalization is unnecessary, the individual requires an environment in
which medication compliance can be fostered. In this case, the group home would provide the
best alternative. The other options do not provide adequate supervision.
DIF: Cognitive level: Analyzing TOP: Nursing process: Planning
MSC: Client Needs: Safe, Effective Care Environment
20. A patient diagnosed with bipolar disorder has stabilized and is being discharged from the
hospital. The patient will live independently at home but lacks social skills and transportation.
Which referral would be most appropriate?
a. A group home
b. A self-help group
c. A day treatment program
d. Assertive community treatment (ACT)
ANS: D
Assertive community treatment (ACT) provides intensive supervision, which includes
assistance with medications and transportation that would support the goal of minimizing
future hospitalizations. A group home is unnecessary because the patient will reside at home.
A day treatment program would provide a therapeutic program directed toward symptoms, but
the patient‘s symptoms have stabilized so this service is not indicated. A self-help group
would not provide the intensity of service this patient needs.
DIF: Cognitive level: Analyzing TOP: Nursing process: Planning
MSC: Client Needs: Safe, Effective Care Environment
,21. A patient diagnosed with long-standing bipolar disorder comes to the mental health center.
The patient says, ―I lost my job and home. Now, I eat in soup kitchens and sleep at a shelter. I
am so depressed that I thought about jumping from a railroad bridge into a river.‖ Which
factor has priority for the nurse who determines the appropriate level of care?
a. Long-standing bipolar disorder
b. Risk for suicide
c. Homelessness
d. Lack of income
ANS: B
Risk assessment shows the patient to have suicidal thoughts, and a plan for the suicide that is
highly lethal, executable, and with low potential for rescue. The other factors do not have as
great an effect on the determination of the level of services needed since they are less related
to acute safety.
DIF: Cognitive level: Analyzing TOP: Nursing process: Evaluation
MSC: Client Needs: Safe, Effective Care Environment
22. When explaining risk assessment, the nurse would indicate that the highest priority for
admission to hospital-based care is associated with which goal?
a. Safety of self and others
b. Minimal confusion and disorientation
c. Successful withdrawal from harmful substances
d. Management of medical illness complicating a psychiatric disorder
ANS: A
The highest priority is safety. In the other situations, threats to safety might or might not exist.
DIF: Cognitive level: Analyzing TOP: Nursing process: Implementation
MSC: Client Needs: Safe, Effective Care Environment
23. What explanation regarding the unit milieu would be most important for the nurse to give to a
newly admitted patient?
a. ―Your behavior will be carefully monitored during your hospital stay.‖
b. ―Unit activities will help you cope with immediate needs and stressors.‖
c. ―You will be given enough medication to bring your symptoms under control.‖
d. ―I will be gathering information about you to plan your care and your discharge.‖
ANS: B
This choice best reflects the purpose of milieu management in psychotherapeutic management
as demonstrated through unit activities. Stating that behavior will be monitored creates
suspicion. Discussing medication administration is a psychopharmacology issue and is not
pertinent to unit milieu. Stating that assessment will take place is not directly related to milieu.
DIF: Cognitive level: Analyzing TOP: Nursing process: Implementation
MSC: Client Needs: Psychosocial Integrity
24. Referral to a psychiatric extended-care facility would be most appropriate for which of the
following patients?
a. An adult with generalized anxiety disorder
b. A severely depressed 70-year-old retiree
, c. A patient with personality disorder who frequently self-mutilates
d. A severely ill person diagnosed with schizophrenia who is regressed and
withdrawn
ANS: D
Extended care often serves those with severe and persistent mental illness and those with a
combination of psychiatric and medical illnesses. The patient demonstrating the signs and
symptoms described in the correct option is at risk for developing psychotic behaviors that
increases the risk for self- and other-directed harm. Patients with anxiety disorders can be
referred to outpatient services. Severely depressed patients would need more intensive care, as
would a self-mutilating individual.
DIF: Cognitive level: Analyzing TOP: Nursing process: Analysis
MSC: Client Needs: Safe, Effective Care Environment
MULTIPLE RESPONSE
1. What data should a nurse analyze when deciding to refer a patient with a psychiatric disorder
to community-based care? (Select all that apply.)
a. Need for PRN medication
b. Severity of the patient‘s illness
c. Need for structured formal therapy
d. Presence of suicidal or homicidal ideation
e. Amount of supervision required by the patient
ANS: B, D, E
The decision tree for the continuum of care calls for the assessment of severity of the illness,
the presence or absence of suicidal or homicidal ideation, whether or not the disability is so
great that the patient is unable to provide for his or her own basic needs, and the amount of
supervision required for patient safety. The frequency of need for PRN medication and the
need for structured formal therapy are not considerations mentioned in the decision tree.
DIF: Cognitive level: Analyzing TOP: Nursing process: Planning
MSC: Client Needs: Safe, Effective Care Environment
2. Which intervention demonstrates that a nurse is functioning within the scope of
psychotherapeutic management? (Select all that apply.)
a. Structuring meaningful unit activities
b. Administering electroconvulsive therapy
c. Encouraging a patient to express feelings
d. Interpreting the results of psychological testing
e. Assessing a patient for medication side effects
ANS: A, C, E
Milieu management, patient communication, and medication administration are all within the
scope of nursing practice. Electroconvulsive therapy is a medical treatment and, therefore,
should be administered by a physician. Psychological testing is interpreted by a psychologist.
DIF: Cognitive level: Analyzing TOP: Nursing process: Implementation
MSC: Client Needs: Safe, Effective Care Environment
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