Chapter 9: The Nursing Process in Psychiatric/Mental Health Nursing

Psychiatric Mental Health Nursing 6th

Edition Mary Townsend Test Bank
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1. A nurse is assessing a newly admitted psychiatric client. Which nursing actions, conducted
during the assessment phase, are a means of data gathering? Select all that apply.
A) Observing the client's interaction with his or her family
B) Consulting with other team members regarding the client's condition
C) Reviewing the client's medical records
D) Explaining the purpose of group attendance and participation

2. A nurse is assessing a newly admitted psychiatric client. Which statement about a psychiatric
assessment is accurate?
A) Medical history is of lesser significance and can be eliminated from the assessment
interview.
B) Psychiatric assessment provides a thorough and holistic overview of the client, including
biological, psychological, and social aspects.
C) Comprehensive assessments can be performed only by physicians.
D) Psychosocial aspects of the evaluation are obtained through subjective reports rather than
objective observations.

3. A nurse is developing a care plan for a newly admitted psychiatric client. Which statement
about nursing diagnoses is correct?
A) Nursing diagnoses are listed on Axis IV of the DSM-IV-TR multiaxial system.
B) Nursing diagnoses are not as important as medical diagnoses.
C) Nursing diagnoses reflect clients' responses to actual or potential problems.
D) Nursing diagnoses are recognized and addressed by other health-related professions.

4. A nurse is developing a care plan for a newly admitted psychiatric client with paranoid
schizophrenia. Which is an appropriate nursing diagnosis for this client?
A) Schizophrenia related to biochemical alterations
B) Self-care deficit (hygiene) related to altered reality orientation
C) Depressed mood related to multiple life stressors
D) Developmental disability related to early onset schizophrenia

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5. A nurse is developing a care plan for a newly admitted psychiatric client. Which are
examples of appropriate outcomes for this client? Select all that apply.
A) Client will feel happier by discharge.
B) Client will demonstrate two relaxation techniques within 1 week.
C) Client will verbalize three triggers to anger by end of session.
D) Client will initiate interaction with one peer during free time within 2 days.

6. A psychiatric nurse is caring for a client in an inpatient unit. Following the client's plan of
care, the nurse performs the interventions ordered for the client. Which statement best
describes nursing interventions?
A) Nursing interventions are autonomous, occurring independently from the treatment team's
goals.
B) Nursing interventions follow the treating physician's orders.
C) Although they are independent nursing actions, nursing interventions occur in concert with
overall treatment team goals.
D) Nursing interventions are not considered independent actions; rather, they reflect the
treatment team's goals.

7. A psychiatric nurse is caring for a client in an inpatient unit. Following the client's plan of
care, the nurse performs the interventions ordered for the client. Which activity should be
performed by advanced-practice psychiatric nurses?
A) Health teaching
B) Case management
C) Milieu therapy
D) Psychotherapy

8. A 39-year-old male client is admitted to a detoxification unit for treatment of alcohol

withdrawal. He is estranged from his wife and children. Because of his alcohol use, he has
also recently lost his job, which was the sole source of income for the family. His wife
refuses to return home until he commits to sobriety. Which independent nursing actions
should a nurse plan to implement? Select all that apply.
A) Initiating psychotherapy
B) Assisting the client to perform activities of daily living (ADLs)
C) Educating the client about signs and symptoms of alcohol dependence and withdrawal
D) Encouraging the client to discuss triggers for relapse

9. A nurse is documenting care in the chart of an inpatient psychiatric client. The nurse charts:
“Refusing all group and individual interactions. States wants to be 'left alone.'” According to
Focus Charting®, this is considered:
A) Data.
B) Focus.
C) Action.
D) Response.

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10. A nurse charts: “Initiated therapeutic relationship with client; attempted one-to-one
interaction; discussed isolative behaviors; provided positive feedback for participation.”
According to Focus Charting®, this documentation is considered:
A) Data.
B) Focus.
C) Action.
D) Response.

11. A psychiatric nurse is performing a mental status examination (MSE) on a newly admitted
client. Elements of an MSE include:
A) Erikson's stage of development.
B) Medical review of systems.
C) Appearance, behavior, speech, mood, affect, intelligence, sensorium, and thought.
D) The family's communication patterns.

12. A nurse asks a client to identify the date, time of day, and location of the clinic. The nurse is
attempting to assess the client's:
A) Mental status.
B) Perception.
C) Orientation.
D) Thought processes.

13. A psychiatric nurse performs an admission assessment for a newly admitted client. The nurse
understands that gathering assessment information is considered:
A) Secondary in importance to diagnostic or laboratory studies.
B) The cornerstone of diagnosis and treatment planning.
C) Useful only for building rapport.
D) Helpful but not necessary for accurate diagnosis and treatment.

14. A 39-year-old male client is admitted to a detoxification unit for treatment of alcohol
withdrawal. He has been on a binge and consumed nothing except beer for the past 2 weeks.
He is estranged from his wife and children.. Because of his alcohol use, he has also recently
lost his job, which was the sole source of income for the family. His wife refuses to return
home until he commits to sobriety. Which nursing diagnoses are relevant to this situation?
Select all that apply.
A) Risk for injury related to central nervous system (CNS) agitation
B) Imbalanced nutrition related to inadequate intake
C) Dysfunctional family processes related to alcoholism
D) Ineffective role performance related to loss of job
E) Fluid volume excess related to binge drinking

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15. A nurse in an inpatient psychiatric unit spends time observing client activity, talking with
clients, and striving to maintain a therapeutic environment in collaboration with other health-
care providers. This specific example of the implementation step of the nursing process is
called:
A) Health teaching.
B) Case management.
C) Milieu therapy.
D) Self-care activities.

16. In preparation for client discharge, a nurse is evaluating whether a client has achieved all
documented, expected outcomes. Which statements are accurate regarding outcomes? Select
all that apply.
A) Expected outcomes are specifically formulated by nurses.
B) Expected outcomes are derived from the nursing diagnosis.
C) Expected outcomes must be measurable and must estimate a time for attainment.
D) Expected outcomes must be realistic for the client's capabilities.

17. A psychiatric nurse is developing a care plan for a newly admitted client. Which statement
about a nursing diagnosis is true?
A) Nursing diagnosis is a new concept.
B) All nurses are required by law to write nursing diagnoses.
C) All nursing diagnoses must be approved by NANDA International.
D) Nursing diagnoses are client responses to actual or potential health problems.

18. After being admitted to an inpatient psychiatric unit, a client is assigned a case manager. The
role of the case manager is to attempt to:
A) Improve the medical welfare system.
B) Ensure that all individuals have medical coverage.
C) Maintain a balance between costs and quality of care.
D) Increase hospital lengths of stay for chronically ill individuals.

19. A psychiatric nurse is developing care plans for multiple inpatient clients. The nurse
understands that nursing diagnoses and associated interventions should be prioritized.
Nursing diagnoses are prioritized according to:
A) The established goal of care.
B) The life-threatening potential.
C) The nurse's priority of care.
D) The client's preference.

20. A client with paranoid schizophrenia is being prepared for discharge. Which client statement
verifies to a nurse that discharge is appropriate?
A) “They are all out to get me.”
B) “Thank you for being kind to me.”
C) “I think my roommate is a spy.”
D) “I don't want anyone to take my stuff.”

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21. A nurse is documenting data in a client's chart. Which statement reflects the documentation
of objective data?
A) “Client states head hurts.”
B) “Client is being mean today.”
C) “Client sitting in chair, playing a game.”
D) “Client is not a pleasant person to speak with.”

22. A psychiatric nurse is caring for a client in an inpatient unit. Following the client's plan of
care, the nurse performs the interventions ordered for the client. Which activity may be
performed by all psychiatric/mental health nurse generalists?
A) Counseling
B) Psychotherapy
C) Consultation
D) Prescriptive authority and treatment

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Answer Key
1. A, B, C
2. B
3. C
4. B
5. B, C, D
6. C
7. D
8. B, C, D
9. A
10. C
11. C
12. C
13. B
14. A, B, C, D
15. C
16. B, C, D
17. D
18. C
19. B
20. B
21. C
22. A

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