Essentials of Psychiatric Mental Health Nursing 3rd Edition Varcarolis Test Bank

Essentials of Psychiatric Mental Health Nursing 3rd Edition Varcarolis Test Bank
Essentials of Psychiatric Mental Health Nursing 3rd

Edition Varcarolis Test Bank
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Chapter 07: Nursing Process and QSEN: The Foundation for Safe and Effective Care
Varcarolis: Essentials of Psychiatric Mental Health Nursing, 3rd Edition
MULTIPLE CHOICE
1. A new staff nurse completes 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. Establish therapeutic relationships.
c. Prescribe psychotropic medication.
d. Individualize nursing care plans.
ANS: C
Prescriptive privileges are granted to Master’s-prepared nurse practitioners who have taken
special courses on prescribing medications. The nurse prepared at the basic level performs
mental health assessments, establishes relationships, and provides individualized care
planning.
DIF: Cognitive Level: Comprehension (Understanding) REF: Page 86

TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment
2. A newly admitted patient diagnosed with major depressive disorder has lost 20 pounds over
the past month 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: Less 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 a suicide attempt.
DIF: Cognitive Level: Application (Applying) REF: Page 83 | Page 84

TOP: Nursing Process: Diagnosis | Nursing Process: Analysis
MSC: NCLEX: Psychosocial Integrity
3. A patient diagnosed with major depressive disorder has lost 20 pounds in one month. The
patient has chronic low self-esteem and a plan for suicide. The patient has taken an
antidepressant medication for 1 week. Which nursing intervention is most directly related to
this priority: “Patient will refrain from gestures and attempts to harm self”?
a. Implement suicide precautions.
b. Frequently offer high-calorie snacks and fluids.
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.

TOP: Nursing Process: Planning MSC: NCLEX: Safe, Effective Care Environment
4. A patient’s nursing diagnosis is insomnia. The desired outcome is: “Patient will sleep for a
minimum of 5 hours nightly by October 31.” On November 1, a review of the sleep data
shows the patient sleeps an average of 4 hours nightly and takes a 2-hour afternoon nap.
Which evaluation should be documented?
a. Consistently demonstrated
b. Often demonstrated
c. Sometimes demonstrated
d. Never demonstrated
ANS: D
Although the patient is sleeping 6 hours daily, the total is not in one uninterrupted session at
night. Therefore the outcome must be evaluated as never demonstrated.

TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
5. A patient’s nursing diagnosis is insomnia. The desired outcome is: “Patient will sleep for a
minimum of 5 hours nightly by October 31.” On November 1, a review of the 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. Revise the outcome target date and interventions.
ANS: D
Sleeping a total of 5 hours at night remains a reasonable outcome. Extending the time frame
for attaining the outcome is 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. At the very least, the time in which the outcome is to be attained
must be extended. Removing this nursing diagnosis from the plan of care could be used when
the outcome goal has been met and the problem resolved. Writing a new nursing diagnosis is
inappropriate because no other nursing diagnosis relates to the problem.

TOP: Nursing Process: Evaluation MSC: NCLEX: 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
b. Analysis
c. Planning
d. Implementation
e. Evaluation
ANS: D
Interventions (implementation) are the nursing prescriptions to achieve the outcomes.
Interventions should be specific.
DIF: Cognitive Level: Comprehension (Understanding) REF: Page 85 | Page 86

TOP: Nursing Process: Implementation MSC: NCLEX: 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. Biased assessments by others should be evaluated as objectively as possible by the
nurse, keeping in mind the possible effects of countertransference.
DIF: Cognitive Level: Application (Applying) REF: Pages 77-82

TOP: Nursing Process: Assessment MSC: NCLEX: Safe, Effective Care Environment
8. A nurse works with a patient to establish outcomes. The nurse believes that one outcome
suggested by the patient is not in the patient’s best interest. What is the nurse’s best action?
a. Remain silent.
b. Educate the patient that the outcome is not realistic.
c. Explore with the patient possible consequences of the outcome.
d. Formulate a more appropriate outcome without the patient’s input.
ANS: C
The nurse should not impose outcomes on the patient; however, the nurse has a responsibility
to help the patient evaluate what is in his or her best interest. Exploring possible consequences
is an acceptable approach.

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
b. Anxiety self-control measures
c. Sleep enhancement activities
d. Suicide precautions
ANS: D
The nurse should place 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.
DIF: Cognitive Level: Analysis (Analyzing) REF: Page 85

TOP: Nursing Process: Planning MSC: NCLEX: Safe, Effective Care Environment
10. Select the best outcome for a patient with this 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.” The patient will:
a. demonstrate improved social skills.
b. express a desire to interact with others.
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 distractors are not measurable.
DIF: Cognitive Level: Analysis (Analyzing) REF: Page 83 | Page 84

TOP: Nursing Process: Outcomes Identification
11. Nursing behaviors associated with the implementation phase of the nursing process are
concerned with:
a. participating in the 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.
DIF: Cognitive Level: Comprehension (Understanding) REF: Page 85 | Page 86

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. The other statements are vague and do not clearly identify the patient’s chief
symptom.
DIF: Cognitive Level: Analysis (Analyzing)
REF: Page 83 (QSEN Box) | Page 84 TOP: Nursing Process: Assessment
MSC: NCLEX: 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 (Prolixin) 2.5 mg 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. I: (Haldol) 2 mg 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 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 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 distractors offer examples of PIE charting, focus documentation, and narrative
documentation.
DIF: Cognitive Level: Analysis (Analyzing) REF: Page 88 (Table 7-4)

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. Document the patient’s mental status. Obtain other assessment data from the
family member.
b. Record the patient’s answers to questions on the nursing assessment form.
c. Ask an advanced practice nurse to perform the assessment interview.
d. Call for a mental health advocate to maintain the patient’s rights.
ANS: A
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
relatives or neighbors who are 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.
DIF: Cognitive Level: Application (Applying) REF: Page 77

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
b. Cognition
c. Affect and mood
d. Perceptual disturbances
ANS: B
Assessing cognition involves determining a patient’s judgment and decision-making
capabilities. In this case, the nurse expects 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.
DIF: Cognitive Level: Application (Applying) REF: Page 80 (Box 7-4)

TOP: Nursing Process: Assessment MSC: NCLEX: 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.” Select the nurse’s best reply.
a. “That is not 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
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 first response is not strictly true. The
second response will not inspire the confidence of the patient. The fourth response is
confrontational.

17. A nurse assessing a new patient asks, “What is meant by the saying, ‘You can’t judge a book
by looking at the cover’?” Which aspect of cognition is the nurse assessing?
a. Mood
b. Attention
c. Orientation
d. Abstraction
ANS: D
Patient interpretation of proverbial statements gives assessment information regarding the
patient’s ability to abstract, which is an aspect of cognition. Mood, orientation, and attention
span are assessed in other ways.

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
18. When a nurse assesses an older adult patient, the patient’s 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.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
19. At one point in an assessment interview a nurse asks, “How does your faith help you in
stressful situations?” This question would be asked during the assessment of:
a. childhood growth and development.
b. substance use and abuse.
c. educational background.
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
seem out of place if introduced during exploration of the other topics.

20. When a new patient is hospitalized, a nurse takes the patient on a tour, explains the rules of
the unit, and discusses the daily schedule. The nurse is engaged in:
a. counseling.
b. health teaching.
c. milieu management.
d. psychobiologic 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 educational needs and giving
information about these needs. Psychobiologic interventions involve medication
administration and monitoring response to medications.
DIF: Cognitive Level: Comprehension (Understanding) REF: Page 86

21. After formulating the nursing diagnoses for a new patient, what is the next action a nurse
should take?
a. Design interventions to include in the plan of care.
b. Determine the goals and outcome criteria.
c. Implement the nursing plan of care.
d. Complete 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 the nursing diagnoses have been
formulated.
DIF: Cognitive Level: Comprehension (Understanding) REF: Page 76 (Fig 7-1) | Page 83
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
b. Ineffective coping
c. Powerlessness
d. Social isolation
ANS: D
Nursing diagnoses are selected on the basis of the etiologic factors and assessment findings or
evidence. In this instance, the evidence shows social isolation that is caused by shyness and
poorly developed social skills.

23. The acronym 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.
DIF: Cognitive Level: Knowledge (Remembering) REF: Page 75 | Page 76

TOP: Nursing Process: N/A MSC: NCLEX: Safe, Effective Care Environment
24. A nurse documents: “Patient is mute, despite repeated efforts to elicit speech. Makes no eye
contact. Is inattentive to staff. Gazes off to the side or looks upward rather than at the
speaker.” Which nursing diagnosis should be considered?
a. Defensive coping
b. Decisional conflict
c. Risk for other-directed violence
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.

MULTIPLE RESPONSE
1. A nurse assesses a patient who reluctantly participates in activities, answers questions with
minimal responses, and rarely makes eye contact. What information should be included when
documenting the assessment? (Select all that apply.)
a. Uncooperative patient
b. Patient’s subjective responses
c. Only data obtained from the patient’s verbal responses
d. Description of the patient’s behavior during the interview
e. Analysis of why the patient is unresponsive during the interview
ANS: B, D
Both the content and process of the interview should be documented. Providing only the
patient’s verbal responses creates a skewed picture of the patient. Writing that the patient is
uncooperative is subjectively worded. An objective description of patient behavior is
preferable. Analysis of the reasons for the patient’s behavior is speculation, which is
inappropriate.

2. A nurse performing an assessment interview for a patient with a substance abuse disorder
decides to use a standardized rating scale. Which scales are appropriate? (Select all that
apply.)
a. Addiction Severity Index (ASI)
b. Brief Drug Abuse Screen Test (B-DAST)
c. Abnormal Involuntary Movement Scale (AIMS)
d. Cognitive Capacity Screening Examination (CCSE)
e. Recovery Attitude and Treatment Evaluator (RAATE)
ANS: A, B, E
Standardized scales are useful for obtaining data concerning substance use disorders. The
ASI, B-DAST, and RAATE are scales related to substance abuse. The AIMS assesses
involuntary movements associated with antipsychotic medications. The CCSE assesses
cognitive function.
DIF: Cognitive Level: Application (Applying)

REF: Page 82 (Table 7-1) | Page 83 TOP: Nursing Process: Assessment
3. What information is conveyed by nursing diagnoses? (Select all that apply.)

a. Medical judgments about the disorder
b. Goals and outcomes for the plan of care
Essentials of Psychiatric Mental Health Nursing 3rd Edition Varcarolis Test Bank
c. Unmet patient needs currently present

d. Supporting data that validate the diagnoses
e. Probable causes that will be targets for nursing interventions
ANS: C, D, E
Nursing diagnoses focus on phenomena of concern to nurses rather than on medical
diagnoses. Goals and outcomes are part of the planning phase.
DIF: Cognitive Level: Comprehension (Understanding) REF: Pages 83-85

MSC: NCLEX: Safe, Effective Care Environment
4. A patient is very suspicious and states, “The FBI has me under surveillance.” Which strategies
should a nurse use when gathering initial assessment data about this patient? (Select all that
apply.)
a. Tell the patient that medication will help this type of thinking.
b. Ask the patient, “Tell me about the problem as you see it.”
c. Seek information about when the problem began.
d. Tell the patient, “Your ideas are not realistic.”
e. Reassure the patient, “You are safe here.”
ANS: B, C, E
During the assessment interview, the nurse should listen attentively and accept the patient’s
statements in a nonjudgmental way. Because the patient is suspicious and fearful, reassuring
safety may be helpful, although trust is unlikely so early in the relationship. Saying that
medication will help or telling the patient that the ideas are not realistic will undermine the
development of trust between the nurse and patient.
DIF: Cognitive Level: Application (Applying) REF: Pages 77-80

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DIF: Cognitive Level: Comprehension (Understanding) REF: Page 86

DIF: Cognitive Level: Application (Applying) REF: Page 83 | Page 84

DIF: Cognitive Level: Application (Applying) REF: Page 83 | Page 84

DIF: Cognitive Level: Application (Applying) REF: Page 87 | Page 88

DIF: Cognitive Level: Application (Applying) REF: Page 87 | Page 88

DIF: Cognitive Level: Comprehension (Understanding) REF: Page 85 | Page 86

DIF: Cognitive Level: Application (Applying) REF: Pages 77-82

DIF: Cognitive Level: Application (Applying) REF: Page 83 | Page 84

DIF: Cognitive Level: Analysis (Analyzing) REF: Page 85

DIF: Cognitive Level: Analysis (Analyzing) REF: Page 83 | Page 84

DIF: Cognitive Level: Comprehension (Understanding) REF: Page 85 | Page 86

DIF: Cognitive Level: Analysis (Analyzing) REF: Page 88 (Table 7-4)

DIF: Cognitive Level: Application (Applying) REF: Page 77

DIF: Cognitive Level: Application (Applying) REF: Page 80 (Box 7-4)

DIF: Cognitive Level: Application (Applying) REF: Page 78

DIF: Cognitive Level: Application (Applying) REF: Page 80 (Box 7-4)

DIF: Cognitive Level: Application (Applying) REF: Page 78

DIF: Cognitive Level: Application (Applying) REF: Page 81 (Box 7-5)

DIF: Cognitive Level: Comprehension (Understanding) REF: Page 86

DIF: Cognitive Level: Application (Applying) REF: Page 83 | Page 84

23. The acronym QSEN refers to:

DIF: Cognitive Level: Knowledge (Remembering) REF: Page 75 | Page 76

DIF: Cognitive Level: Application (Applying) REF: Page 83 | Page 84

DIF: Cognitive Level: Application (Applying) REF: Page 77 | Page 87

DIF: Cognitive Level: Application (Applying)

3. What information is conveyed by nursing diagnoses? (Select all that apply.)

c. Unmet patient needs currently present

DIF: Cognitive Level: Comprehension (Understanding) REF: Pages 83-85

DIF: Cognitive Level: Application (Applying) REF: Pages 77-80

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