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Varcarolis: Chapter 7 - The Nursing Process and Standards of Care for Psychiatric Mental Health Nursing

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Varcarolis: Chapter 7 - The Nursing Process and Standards of Care for Psychiatric Mental Health Nursing Question 1: A new staff nurse completes an orientation to the psychiatric unit. This nurse will expect to ask an advanced practice nurse to perform which action for patients? - a. Perform...

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  • August 16, 2024
  • 17
  • 2024/2025
  • Exam (elaborations)
  • Questions & answers

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Varcarolis: Chapter 7 - The Nursing Process and Standards of Care
for Psychiatric Mental Health Nursing


Question 1:

A new staff nurse completes an orientation to the psychiatric unit. This nurse will expect to ask an
advanced practice nurse to perform which action for patients?

- a. Perform mental health assessment interviews.

- b. Prescribe psychotropic medication.

- c. Establish therapeutic relationships.

- d. Individualize nursing care plans.



Answer: b. Prescribe psychotropic medication.

Feedback: Advanced practice nurses, such as nurse practitioners, have prescriptive privileges and the
ability to prescribe medications after receiving additional training, while basic nursing roles do not
include this privilege.



---



Question 2:

A newly admitted patient diagnosed with major depression has gained 20 pounds over a few months
and has suicidal ideation. The patient has taken antidepressant medication for 1 week without remission
of symptoms. Select the priority nursing diagnosis.

- a. Imbalanced nutrition: more than body requirements

- b. Chronic low self-esteem

- c. Risk for suicide

- d. Hopelessness



Answer: c. Risk for suicide

Feedback: Given the presence of suicidal ideation, the priority nursing diagnosis must focus on patient
safety to address immediate risks.

,---



Question 3:

A patient diagnosed with major depression has lost 20 pounds in one month, has chronic low self-
esteem, and a plan for suicide. The patient has taken antidepressant medication for 1 week. Which
nursing intervention has the highest priority?

- a. Implement suicide precautions.

- b. Offer high-calorie snacks and fluids frequently.

- c. Assist the patient to identify three personal strengths.

- d. Observe patient for therapeutic effects of antidepressant medication.



Answer: a. Implement suicide precautions.

Feedback: Ensuring patient safety through suicide precautions is the highest priority when there is an
active plan for suicide, as it directly addresses immediate danger.



---



Question 4:

The desired outcome for a patient experiencing insomnia is, "Patient will sleep for a minimum of 5 hours
nightly within 7 days." At the end of 7 days, review of sleep data shows the patient sleeps an average of
4 hours nightly and takes a 2-hour afternoon nap. The nurse will document the outcome as:

- a. consistently demonstrated.

- b. often demonstrated.

- c. sometimes demonstrated.

- d. never demonstrated.



Answer: d. never demonstrated.

Feedback: Since the patient did not meet the minimum requirement of 5 uninterrupted hours of sleep at
night, this outcome is evaluated as "never demonstrated."



---

, Question 5:

The desired outcome for a patient experiencing insomnia is, "Patient will sleep for a minimum of 5 hours
nightly within 7 days." At the end of 7 days, the review of sleep data shows the patient sleeps an
average of 4 hours nightly and takes a 2-hour afternoon nap. What is the nurse's next action?

- a. Continue the current plan without changes.

- b. Remove this nursing diagnosis from the plan of care.

- c. Write a new nursing diagnosis that better reflects the problem.

- d. Examine interventions for possible revision of the target date.



Answer: d. Examine interventions for possible revision of the target date.

Feedback: Extending the timeline for achieving the sleep goal while also considering modifications to
interventions is a sensible next step in managing the patient's care.



---



Question 6:

A patient begins a new program to assist with building social skills. In which part of the plan of care
should a nurse record the item, "Encourage patient to attend one psychoeducational group daily"?

- a. Assessment

- b. Analysis

- c. Implementation

- d. Evaluation



Answer: c. Implementation

Feedback: Interventions such as encouraging attendance at psychoeducational groups are recorded
under the implementation section, where specific actions to achieve patient goals are documented.



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