Chapter 8. The Nursing Process in Psychiatric-Mental Health Nursing
MULTIPLE CHOICE
1. Which data-gathering technique is employed during the assessment phase of the nursing
process?
1. Asking the client to rate mood after administering an antidepressant
2. Asking the client to verbalize understanding of previously explained unit rules
3. Asking the client to describe any thoughts of self-harm
4. Asking the client if the group on assertiveness skills was helpfaublirb.com/test
ANS: 3
Chapter: Chapter 8, The Nursing Process in Psychiatric-Mental Habeirabl.tchomN/teusrt sing
Objective: Identify six steps of the nursing process and describe nursing actions associated
with each.
Page: 139
Heading: The Nursing Process > Standards of Practice > Standaradbi1rb..cAoms/st esstsment
Integrated Processes: Nursing Process: Assessment
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Communication
Difficulty: Moderate
Feedback
1. This is incorrect. The client is asked to rate mood during the evaluation phase of the
nursing process.
2. This is incorrect. The client is asked to verbalize understanadbirnb.coomf/tepsrteviously
explained unit rules during the evaluation phase of the nursing process.
3. This is correct. The nurse should ask the client to describe any thoughts of self-harm
during the assessment phase of the nursing process. Assessambirebn.ctomin/tvesot lves
collecting and analyzing data about the client that may include the following
dimensions: physical, psychological, sociocultural, spiritual, cognitive,
developmental, economic,
lifestyle,
4. This and functional
is incorrect. abilities.
The client is asked if the group on sm/steksitlls was
asserti v e n e s
a b ir b. c o helpful
during the evaluation phase of the nursing process.
CON: Communication
2. Which statement is most accurate regarding the assessment of acbliribe.ncotms /dteisat
gnosed 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 advancaebdirbp.croamc/tteicste nurses.
4. Psychosocial evaluations are gained by subjective reports rather than objective
observations.
ANS: 2
Chapter: Chapter 8, The Nursing Process in Psychiatric-Mental Health Nursing
Objective: Apply the six steps of the nursing process in caring for a client within the
psychiatric setting.
Page: 140
Heading: The Nursing Process> Standards of Practice > Standard 1. Assessment
Integrated Processes: Nursing Process: Assessment Client Need:
Safe and Effective Care Environment: Management of Care Cognitive Level:
Comprehension [Understanding]
Concept: Patient-Centered Care
Difficulty: Moderate
Feedback
1. This is incorrect. A client’s medical history is significant aanbdirbs.choomu/tledst be part
of the
2. nursing
This assessment.
is correct. Assessment of clients diagnosed with psychiatric problems provides
a holistic view of the client. A thorough assessment involvaebsirbc.ocollme/ctetsitng
and analyzing data from the client, significant others, and health-care providers that
may include the following dimensions: physical, psychological, sociocultural,
spiritual,
3. cognitive,
This developmental,
is incorrect. economic,
All registered nurseslifestyle, and functional
can perform compreahbiabilities.
erbn.csoimve/tecstlient
assessments.
4. This is incorrect. Psychosocial evaluations are gained by both subjective reports and
objective observations.
CON: Patient-Centered Care
3. Which nursing diagnosis is correctly formulated?
1. Schizophrenia related to (R/T) biochemical alterations as
evideabnircbe.cdomb/ytes(tAEB) altered thought
2. Self-care deficit: hygiene R/T altered thought AEB disheveled appearance
3. Depressed mood R/T multiple life stressors
4. Developmental disability R/T early-onset schizophrenia AEB ahbairlbl.ucocmin/taesttions
ANS: 2
Chapter: Chapter 8, The Nursing Process in Psychiatric-Mental Habeirabl.tchomN/teusrt sing
Objective: Apply the six steps of the nursing process in caring for a client within the
, psychiatric setting.
Page: 147
Heading: The Nursing Process > Appendix F, Assigning NANDA Nursing Diagnoses to
Client Behaviors
Integrated Processes: Nursing Process: Analysis
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
Feedback
1. This is incorrect. The nursing diagnosis should describe the unhealthy response
(inference).
2. This is correct. The correctly written diagnosis is “Self-caraebidrbe.cfoicmi/te:sht ygiene
R/T
altered thought AEB disheveled appearance.” This nursing diagnosis describes the
unhealthy response (inference), the contributing factors, and the data that support the
3. inference.
This is incorrect. The nursing diagnosis should describe the data that support the
inference.
4. This is incorrect. The nursing diagnosis should describe the unhealthy response
(inference), the contributing factors, and the data that suppaobrirtbt.choemi/tnesfterence.
CON: Patient-Centered Care
4. Which is a correctly stated client outcome?
1. Client will feel happier by discharge.
2. Client will demonstrate two relaxation techniques.
3. Client will verbalize triggers to anger by end of session.
4. Client will initiate interaction with one peer during free time waibtirhbi.cnom2/tdesatys.
ANS: 4
Chapter: Chapter 8, The Nursing Process in Psychiatric-Mental Health Nursing
Objective: Apply the six steps of the nursing process in caring ithin the
foarbairbc.cloimen/tet swt
psychiatric setting.
Page: 147
Heading: The Nursing Process > Standards of Practice >Standardab3ir.b.Ocoumt/cteostmes
Identification
Integrated Processes: Nursing Process: Planning
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Comprehension [Understanding]
Concept: Patient-Centered Care
Difficulty: Easy
Feedback
1. This is incorrect. This client outcome is not measurable.
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