Varcarolis’ Foundations of Psychiatric Mental Health Nursing A Clinical Approach 7th Edition By Margaret Jordan Halter

Varcarolis’ Foundations of Psychiatric Mental Health Nursing A Clinical Approach 7th Edition By Margaret Jordan Halter

Chapter 07: The Nursing Process and Standards of Care for Psychiatric Mental Health Nursing

MULTIPLE CHOICE

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.

ANS: B
Prescriptive privileges are granted to master’s-prepared nurse practitioners who have taken special courses on prescribing medication. The nurse prepared at the basic level performs mental health assessments, establishes relationships, and provides individualized care planning. Note that this question was also offered for Chapter 1.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)
REF: Page 127 TOP: Nursing Process: Implementation
MSC: Client Needs: Safe, Effective Care Environment

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 an 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

ANS: C
Risk for suicide is the priority diagnosis when the patient has both suicidal ideation and a plan to carry out the suicidal intent. Imbalanced nutrition, hopelessness, and chronic low self-esteem may be applicable nursing diagnoses, but these problems do not affect patient safety as urgently as would a suicide attempt.

PTS: 1 DIF: Cognitive Level: Analyze (Analysis)
REF: Page 123-124 TOP: Nursing Process: Diagnosis/Analysis
MSC: Client Needs: Psychosocial Integrity

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 an 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.

ANS: A
Implementing suicide precautions is the only option related to patient safety. The other options, related to nutrition, self-esteem, and medication therapy, are important but are not priorities.

PTS: 1 DIF: Cognitive Level: Analyze (Analysis)
REF: Page 126-127 TOP: Nursing Process: Planning
MSC: Client Needs: Safe, Effective Care Environment

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. c. sometimes demonstrated.
b. often demonstrated. d. never demonstrated.

ANS: D
Although the patient is sleeping 6 hours daily, the total is not one uninterrupted session at night. Therefore, the outcome must be evaluated as never demonstrated. See relationship to audience response question.

PTS: 1 DIF: Cognitive Level: Apply (Application)
REF: Page 127 TOP: Nursing Process: Evaluation
MSC: Client Needs: Physiological Integrity

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, 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.

ANS: D
Sleeping a total of 5 hours at night remains a reasonable outcome. Extending the period for attaining the outcome may be appropriate. Examining interventions might result in planning an activity during the afternoon rather than permitting a nap. Continuing the current plan without changes is inappropriate. Removing this nursing diagnosis from the plan of care would be correct when the outcome was met and the problem resolved. Writing a new nursing diagnosis is inappropriate because no other nursing diagnosis relates to the problem.

PTS: 1 DIF: Cognitive Level: Apply (Application)
REF: Page 127 TOP: Nursing Process: Evaluation
MSC: Client Needs: Physiological Integrity

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 c. Implementation
b. Analysis d. Evaluation

ANS: C
Interventions are the nursing prescriptions to achieve the outcomes. Interventions should be specific.

PTS: 1 DIF: Cognitive Level: Apply (Application)
REF: Page 126-127 TOP: Nursing Process: Implementation
MSC: Client Needs: Psychosocial Integrity

7. Before assessing a new patient, a nurse is told by another health care worker, “I know that patient. No matter how hard we work, there isn’t much improvement by the time of discharge.” The nurse’s responsibility is to:
a. document the other worker’s assessment of the patient.
b. assess the patient based on data collected from all sources.
c. validate the worker’s impression by contacting the patient’s significant other.
d. discuss the worker’s impression with the patient during the assessment interview.

ANS: B
Assessment should include data obtained from both the primary and reliable secondary sources. The nurse, bearing in mind the possible effects of counter-transference, should evaluate biased assessments by others as objectively as possible.

PTS: 1 DIF: Cognitive Level: Apply (Application)
REF: Page 117-118 TOP: Nursing Process: Assessment
MSC: Client Needs: Safe, Effective Care Environment

8. A patient presents to the emergency department with mixed psychiatric symptoms. The admission nurse suspects the symptoms may be the result of a medical problem. Lab results show elevated BUN (blood urea nitrogen) and creatinine. What is the nurse’s next best action?
a. Report the findings to the health care provider.
b. Assess the patient for a history of renal problems.
c. Assess the patient’s family history for cardiac problems.
d. Arrange for the patient’s hospitalization on the psychiatric unit.

ANS: B
Elevated BUN (blood urea nitrogen) and creatinine suggest renal problems. Renal dysfunction can often imitate psychiatric disorders. The nurse should further assess the patient’s history for renal problems and then share the findings with the health care provider.

PTS: 1 DIF: Cognitive Level: Analyze (Analysis)
REF: Page 119-120 (Box 7-3) TOP: Nursing Process: Assessment
MSC: Client Needs: Physiological Integrity

9. A patient states, “I’m not worth anything. I have negative thoughts about myself. I feel anxious and shaky all the time. Sometimes I feel so sad that I want to go to sleep and never wake up.” Which nursing intervention should have the highest priority?
a. Self-esteem–building activities c. Sleep enhancement activities
b. Anxiety self-control measures d. Suicide precautions

ANS: D
The nurse would place a priority on monitoring and reinforcing suicide self-restraint because it relates directly and immediately to patient safety. Patient safety is always a priority concern. The nurse should monitor and reinforce all patient attempts to control anxiety, improve sleep patterns, and develop self-esteem, while giving priority attention to suicide self-restraint.

PTS: 1 DIF: Cognitive Level: Analyze (Analysis)
REF: Page 124-125 (Table 7-2) | Page 125 (Table 7-3) TOP: Nursing Process: Planning
MSC: Client Needs: Safe, Effective Care Environment

10. Select the best outcome for a patient with the nursing diagnosis: Impaired social interaction related to sociocultural dissonance as evidenced by stating, “Although I’d like to, I don’t join in because I don’t speak the language very well.” Patient will:
a. show improved use of language.
b. demonstrate improved social skills.
c. become more independent in decision making.
d. select and participate in one group activity per day.

ANS: D
The outcome describes social involvement on the part of the patient. Neither cooperation nor independence has been an issue. The patient has already expressed a desire to interact with others. Outcomes must be measurable. Two of the distracters are not measurable.

PTS: 1 DIF: Cognitive Level: Analyze (Analysis)
REF: Page 124 TOP: Nursing Process: Outcomes Identification
MSC: Client Needs: Psychosocial Integrity

11. Nursing behaviors associated with the implementation phase of nursing process are concerned with:
a. participating in mutual identification of patient outcomes.
b. gathering accurate and sufficient patient-centered data.
c. comparing patient responses and expected outcomes.
d. carrying out interventions and coordinating care.

ANS: D
Nursing behaviors relating to implementation include using available resources, performing interventions, finding alternatives when necessary, and coordinating care with other team members.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)
REF: Page 126-127 TOP: Nursing Process: Implementation
MSC: Client Needs: Safe, Effective Care Environment

12. Which statement made by a patient during an initial assessment interview should serve as the priority focus for the plan of care?
a. “I can always trust my family.”
b. “It seems like I always have bad luck.”
c. “You never know who will turn against you.”
d. “I hear evil voices that tell me to do bad things.”

ANS: D
The statement regarding evil voices tells the nurse that the patient is experiencing auditory hallucinations and may create risks for violence. The other statements are vague and do not clearly identify the patient’s chief symptom.

PTS: 1 DIF: Cognitive Level: Analyze (Analysis)
REF: Page 117 | Page 120-121 TOP: Nursing Process: Assessment
MSC: Client Needs: Physiological Integrity

13. Which entry in the medical record best meets the requirement for problem-oriented charting?
a. “A: Pacing and muttering to self. P: Sensory perceptual alteration related to internal auditory stimulation. I: Given fluphenazine HCL (Prolixin) 2.5 mg po at 0900 and went to room to lie down. E: Calmer by 0930. Returned to lounge to watch TV.”
b. “S: States, ‘I feel like I’m ready to blow up.’ O: Pacing hall, mumbling to self. A: Auditory hallucinations. P: Offer haloperidol (Haldol) 2 mg po. I: Haloperidol (Haldol) 2 mg po given at 0900. E: Returned to lounge at 0930 and quietly watched TV.”
c. “Agitated behavior. D: Patient muttering to self as though answering an unseen person. A: Given haloperidol (Haldol) 2 mg po and went to room to lie down. E: Patient calmer. Returned to lounge to watch TV.”
d. “Pacing hall and muttering to self as though answering an unseen person. haloperidol (Haldol) 2 mg po administered at 0900 with calming effect in 30 minutes. Stated, ‘I’m no longer bothered by the voices.’”

ANS: B
Problem-oriented documentation uses the first letter of key words to organize data: S for subjective data, O for objective data, A for assessment, P for plan, I for intervention, and E for evaluation. The distracters offer examples of PIE charting, focus documentation, and narrative documentation.

PTS: 1 DIF: Cognitive Level: Analyze (Analysis)
REF: Page 127-128 (Table 7-4) TOP: Nursing Process: Implementation
MSC: Client Needs: Safe, Effective Care Environment

14. A nurse assesses an older adult patient brought to the emergency department by a family member. The patient was wandering outside saying, “I can’t find my way home.” The patient is confused and unable to answer questions. Select the nurse’s best action.
a. Record the patient’s answers to questions on the nursing assessment form.
b. Ask an advanced practice nurse to perform the assessment interview.
c. Call for a mental health advocate to maintain the patient’s rights.
d. Obtain important information from the family member.

ANS: D
When the patient (primary source) is unable to provide information, secondary sources should be used, in this case, the family member. Later, more data may be obtained from other information sources familiar with the patient. An advanced practice nurse is not needed for this assessment; it is within the scope of practice of the staff nurse. Calling a mental health advocate is unnecessary. See relationship to audience response question.

PTS: 1 DIF: Cognitive Level: Apply (Application)
REF: Page 118-119 | Page 122-123 TOP: Nursing Process: Assessment
MSC: Client Needs: Safe, Effective Care Environment

15. A nurse asks a patient, “If you had fever and vomiting for 3 days, what would you do?”
Which aspect of the mental status examination is the nurse assessing?
a. Behavior c. Affect and mood
b. Cognition d. Perceptual disturbances

ANS: B
Assessing cognition involves determining a patient’s judgment and decision making. In this case, the nurse would expect a response of “Call my doctor” if the patient’s cognition and judgment are intact. If the patient responds, “I would stop eating” or “I would just wait and see what happened,” the nurse would conclude that judgment is impaired. The other options refer to other aspects of the examination.

PTS: 1 DIF: Cognitive Level: Apply (Application)
REF: Page 121 (Box 7-4) TOP: Nursing Process: Assessment
MSC: Client Needs: Psychosocial Integrity

16. An adolescent asks a nurse conducting an assessment interview, “Why should I tell you anything? You’ll just tell my parents whatever you find out.” Which response by the nurse is appropriate?
a. “That isn’t true. What you tell us is private and held in strict confidence. Your parents have no right to know.”
b. “Yes, your parents may find out what you say, but it is important that they know about your problems.”
c. “What you say about feelings is private, but some things, like suicidal thinking, must be reported to the treatment team.”
d. “It sounds as though you are not really ready to work on your problems and make changes.”

ANS: C
Adolescents are very concerned with confidentiality. The patient has a right to know that most information will be held in confidence but that certain material must be reported or shared with the treatment team, such as threats of suicide, homicide, use of illegal drugs, or issues of abuse. The incorrect responses are not true, will not inspire the confidence of the patient, or are confrontational.

PTS: 1 DIF: Cognitive Level: Apply (Application)
REF: Page 118 TOP: Nursing Process: Implementation
MSC: Client Needs: Safe, Effective Care Environment

17. A nurse wants to assess an adult patient’s recent memory. Which question would best yield the desired information?
a. “Where did you go to elementary school?”
b. “What did you have for breakfast this morning?”
c. “Can you name the current president of the United States?”
d. “A few minutes ago, I told you my name. Can you remember it?”

ANS: B
The patient’s recall of a meal provides evidence of recent memory. Two incorrect responses are useful to assess immediate and remote memory. The other distracter assesses the patient’s fund of knowledge.

PTS: 1 DIF: Cognitive Level: Apply (Application)
REF: Page 121 (Box 7-4) TOP: Nursing Process: Assessment
MSC: Client Needs: Psychosocial Integrity

18. When a nurse assesses an older adult patient, answers seem vague or unrelated to the questions. The patient also leans forward and frowns, listening intently to the nurse. An appropriate question for the nurse to ask would be:
a. “Are you having difficulty hearing when I speak?”
b. “How can I make this assessment interview easier for you?”
c. “I notice you are frowning. Are you feeling annoyed with me?”
d. “You’re having trouble focusing on what I’m saying. What is distracting you?”

ANS: A
The patient’s behaviors may indicate difficulty hearing. Identifying any physical need the patient may have at the onset of the interview and making accommodations are important considerations. By asking if the patient is annoyed, the nurse is jumping to conclusions. Asking how to make the interview easier for the patient may not elicit a concrete answer. Asking about distractions is a way of asking about auditory hallucinations, which is not appropriate because the nurse has observed that the patient seems to be listening intently.

PTS: 1 DIF: Cognitive Level: Apply (Application)
REF: Page 118-119 TOP: Nursing Process: Assessment
MSC: Client Needs: Physiological Integrity

19. At what point in an assessment interview would a nurse ask, “How does your faith help you in stressful situations?” During the assessment of:
a. childhood growth and development c. educational background
b. substance use and abuse d. coping strategies

ANS: D
When discussing coping strategies, the nurse might ask what the patient does when upset, what usually relieves stress, and to whom the patient goes to talk about problems. The question regarding whether the patient’s faith helps deal with stress fits well here. It would be out of place if introduced during exploration of the other topics.

PTS: 1 DIF: Cognitive Level: Apply (Application)
REF: Page 120-121 (Box 7-5) TOP: Nursing Process: Assessment
MSC: Client Needs: Psychosocial Integrity

20. When a new patient is hospitalized, a nurse takes the patient on a tour, explains rules of the unit, and discusses the daily schedule. The nurse is engaged in:
a. counseling. c. milieu management.
b. health teaching. d. psychobiological intervention.

ANS: C
Milieu management provides a therapeutic environment in which the patient can feel comfortable and safe while engaging in activities that meet the patient’s physical and mental health needs. Counseling refers to activities designed to promote problem solving and enhanced coping and includes interviewing, crisis intervention, stress management, and conflict resolution. Health teaching involves identifying health education needs and giving information about these needs. Psychobiological interventions involve medication administration and monitoring response to medications.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)
REF: Page 126-127 TOP: Nursing Process: Implementation
MSC: Client Needs: Safe, Effective Care Environment

21. After formulating the nursing diagnoses for a new patient, what is a nurse’s next action?
a. Designing interventions to include in the plan of care
b. Determining the goals and outcome criteria
c. Implementing the nursing plan of care
d. Completing the spiritual assessment

ANS: B
The third step of the nursing process is planning and outcome identification. Outcomes cannot be determined until the nursing assessment is complete and nursing diagnoses have been formulated.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)
REF: Page 123-124 TOP: Nursing Process: Implementation
MSC: Client Needs: Safe, Effective Care Environment

22. Select the most appropriate label to complete this nursing diagnosis: ___________ related to feelings of shyness and poorly developed social skills as evidenced by watching television alone at home every evening.
a. Deficient knowledge c. Social isolation
b. Ineffective coping d. Powerlessness

ANS: C
Nursing diagnoses are selected based on the etiological factors and assessment findings, or evidence. In this instance, the evidence shows social isolation that is caused by shyness and poorly developed social skills.

PTS: 1 DIF: Cognitive Level: Apply (Application)
REF: Page 123-124 TOP: Nursing Process: Diagnosis/Analysis
MSC: Client Needs: Psychosocial Integrity

23. “QSEN” refers to:
a. Qualitative Standardized Excellence in Nursing
b. Quality and Safety Education for Nurses
c. Quantitative Effectiveness in Nursing
d. Quick Standards Essential for Nurses

ANS: B
QSEN represents national initiatives centered on patient safety and quality. The primary goal of QSEN is to prepare future nurses with the knowledge, skills, and attitudes to increase the quality, care, and safety in the health care setting in which they work.

PTS: 1 DIF: Cognitive Level: Remember (Knowledge)
REF: Page 115-117 (Box 7-1) TOP: Nursing Process: N/A
MSC: Client Needs: Safe, Effective Care Environment

24. A nurse documents: “Patient is mute despite repeated efforts to elicit speech. Makes no eye contact. Inattentive to staff. Gazes off to the side or looks upward rather than at speaker.” Which nursing diagnosis should be considered?
a. Defensive coping c. Risk for other-directed violence
b. Decisional conflict d. Impaired verbal communication

ANS: D
The defining characteristics are more related to the nursing diagnosis of impaired verbal communication than to the other nursing diagnoses.

PTS: 1 DIF: Cognitive Level: Apply (Application)
REF: Page 123-124 TOP: Nursing Process: Diagnosis/Analysis
MSC: Client Needs: Psychosocial Integrity

25. A nurse prepares to assess a new patient who moved to the United States from Central America three years ago. After introductions, what is the nurse’s next comment?
a. “How did you get to the United States?”
b. “Would you like for a family member to help you talk with me?”
c. “An interpreter is available. Would you like for me to make a request for these services?”
d. “Are you comfortable conversing in English, or would you prefer to have a translator present?”

ANS: D
The nurse should determine whether a translator is needed by first assessing the patient for language barriers. Accuracy of the assessment depends on the ability to communicate in a language that is familiar to the patient. Family members are not always reliable translators. An interpreter may change the patient’s responses; a translator is a better resource.

PTS: 1 DIF: Cognitive Level: Analyze (Analysis)
REF: Page 118-119 TOP: Nursing Process: Assessment
MSC: Client Needs: Psychosocial Integrity