Chapter.9

Question 1

Which data gathering technique is employed during the assessment phase of the nursing process?

A.Asking the client to rate mood after administering an antidepressant
B.Asking the client to verbalize understanding of previously explained unit rules
C.Asking the client to describe any thoughts of self-harm
D.Asking the client if the group on assertiveness skills was helpful

Answer 1

C

Question 2

Which statement is most accurate regarding the assessment of clients diagnosed with psychiatric problems?

A.Medical history is of little significance and can be eliminated from the nursing assessment.
B.Assessment provides a holistic view of the
client including biopsychosocial aspects.
C.Comprehensive assessments can be performed only by advanced practice nurses.
D.Psychosocial evaluations are gained by subjective reports rather than objective observations.

Answer 2

B

Question 3

Which nursing diagnosis should a nurse identify as being correctly formulated?

A.Schizophrenia R/T biochemical alterations AEB altered thought
B.Self-care deficit: hygiene R/T altered thought as AEB disheveled appearance
C.Depressed mood R/T multiple life stressors
D.Developmental disability R/T early-onset schizophrenia AEB hallucinations

Answer 3

B

Question 4

Which expected client outcome should a nurse identify as being correctly formulated?
A.Client will feel happier by discharge.
B.Client will demonstrate two relaxation techniques.
C.Client will verbalize triggers to anger by end of session.
D.Client will initiate interaction with one peer during free time within 2 days.

Answer 4

D

Question 5

Which statement regarding nursing interventions should a nurse identify as accurate?

A.Nursing interventions are independent from the treatment team’s goals.
B.Nursing interventions are solely directed by written physician orders.
C.Nursing interventions occur independently but in concert with overall treatment team goals.
D.Nursing interventions are standardized by policies and procedures.

Answer 5

C

Question 6

Within the nurse’s scope of practice, which function is exclusive to the advance practice psychiatric nurse?
A.Teaching about the side effects of neuroleptic medications
B.Using psychotherapy to improve mental health status
C.Using milieu therapy to structure a therapeutic environment
D.Providing case management to coordinate continuity of health services

Answer 6

B

Question 7

A nurse charts “Verbalizes understanding of the side effects of Prozac.” This is an example of which category of focused charting?

A.Data
B.Problem
C.Action
D.Response

Answer 7

D

Question 8

The nurse should recognize which acronym as representing problem-oriented charting?

A.SOAPIE
B.APIE
C.DAR
D.PQRST

Answer 8

A

Question 9

Which tool would be appropriate for a nurse to use when assessing mental acuity prior to and immediately following electroconvulsive therapy (ECT)?

A.CIWA scale
B.GGT
C.MMSE
D.CAPS scale

Answer 9

C

Question 10

What is being assessed when a nurse asks a client to identify name, date, residential address, and situation?

A.Mood
B.Perception
C.Orientation
D.Affect

Answer 10

C

Question 11

What is the purpose when a nurse gathers client information?
A.It enables the nurse to modify client behaviors related to personality disorders.
B.It enables the nurse to make sound clinical judgments and plan appropriate client care.
C.It enables the nurse to prescribe the appropriate medications.
D.It enables the nurse to assign the appropriate Axis I diagnosis.

Answer 11

B

Question 12

A nurse on an inpatient psychiatric unit implements care by scheduling client activities, interacting with clients, and maintaining a safe therapeutic environment. These actions reflect which role of the nurse?

A.Health teacher
B.Case manager
C.Milieu manager
D.Psychotherapist

Answer 12

C

Question 13

The following outcome was developed for a client: “Client will list five personal strengths by the end of day 1.” Which correctly written nursing diagnostic statement most likely generated the development of this outcome?
A.Altered self-esteem R/T years of emotional abuse AEB self-deprecating statements
B.Self-care deficit R/T altered thought processes
C.Disturbed body image R/T major depressive disorder AEB mood rating of 2/10
D.Risk for disturbed self-concept R/T hopelessness AEB suicide attempt

Answer 13

A

Question 14

How should a nurse prioritize nursing diagnoses?

A.By the established goal of care
B.By the life-threatening potential
C.By the physician’s priority of care
D.By the client’s preference

Answer 14

B

Question 15

A client has a nursing diagnosis of Insomnia R/T paranoid thinking AEB midnight awakenings, difficulty falling asleep, and daytime napping. Which is a correctly written and appropriate outcome for this client’s problem?

A.The client will avoid daytime napping and attend all groups.
B.The client will exercise, as needed, before bedtime.
C.The client will sleep 7 uninterrupted hours by day four of hospitalization.
D.The client’s sleep habits will improve during hospitalization.

Answer 15

C

Question 16

The following North American Nursing Diagnosis Association (NANDA) nursing diagnostic stem was developed for a client on an inpatient unit: Risk for injury. What assessment data most likely led to the development of this problem statement?

A.The client is receiving electroconvulsive therapy (ECT) and is diagnosed with Parkinsonism.
B.The client has a history of four suicide attempts in adolescence.
C.The client expresses hopelessness and helplessness and isolates self.
D.The client has disorganized thought processes and delusional thinking.

Answer 16

A

Question 17

A student nurse asks an instructor how best to develop nursing outcomes for clients. Which reply by the instructor most accurately answers the student’s question?

A.“Use the Nursing Interventions Classification (NIC) as a reference for nursing outcomes.”
B.“Look at your client’s problems and set a realistic, achievable goal.”
C.“Use the Nursing Outcomes Classification (NOC) as a reference for nursing outcomes.”
D.“Copy your standard outcomes from a nursing care plan textbook.”

Answer 17

C

Question 18

A client diagnosed with schizophrenia is exhibiting nonverbal behaviors indicating that the client is hearing things that others do not. Which nursing diagnosis accurately reflects this client’s problem?

A.Altered thought processes
B.Altered sensory perception
C.Anxiety
D.Chronic confusion

Answer 18

B

Question 19

A nurse is evaluating the effectiveness of teaching after instructing a group of clients on joint replacement. In the evaluation step of the nursing process, which learning domain is the most difficult to measure?
A.Normative domain
B.Affective domain
C.Cognitive domain
D.Psychomotor domain

Answer 19

B

Question 20

A client is recovering from abdominal surgery. In order to maximize the learning process prior to discharge teaching, which assessment should be performed by the nurse?
A.Assessing the client’s level of pain
B.Assessing and documenting the client’s vital signs
C.Assessing skin turgor and hydration status
D.Assessing incisional site for serosanguineous drainage

Answer 20

A

Question 21

During the implementation phase of the nursing process, a nurse is teaching an adult with a cochlear implant about medications. Which modification in the teaching plan would be the most appropriate for this client?
A.Using repetition
B.Speaking directly face-to-face
C.Employing the use of sign language
D.Providing large-print materials

Answer 21

B

Question 22

A client who has slept 6 hours the previous night reports this to the assigned psychiatric nurse. What should be the initial nursing action to address this situation?

A.Provide warm milk and a backrub.
B.Give a sleep medication.
C.Hold a relaxation group before bedtime.
D.Review the client’s normal sleep pattern.

Answer 22

D

Question 23

An instructor overhears a student say, “That family seems to disagree more than agree. The family seems to be dysfunctional.” To further assess the family’s situation, which would be an appropriate instructor reply?

A.“Families who disagree can be a challenge to the treatment team.”
B.“You seem very critical of the family. Do you believe that you are unable to help them?”
C.“Let’s bring the family in for an educational session to improve their communication.”
D.“What appears to trigger family disagreements?”

Answer 23

D

Question 24

Which nursing response would be appropriately used in the evaluation phase of the nursing process?

A.“If I were in your situation, I would not repeat a behavior that has caused problems.”
B.“What do you think needs changing, and what do you want to do differently?”
C.“What exactly will it take to carry out your plan, and what else do you need to do?”
D.“This new approach seems to work for you.”

Answer 24

D

Question 25

A client diagnosed with major depressive disorder states, “Why should I keep trying to get a job? I mess up everything I do.” Which correctly written nursing diagnosis best reflects the content and mood themes in this client’s statement? A.Hopelessness R/T poor job performance B.Risk for impaired adjustment R/T inadequate social skills AEB isolation C.Altered role performance R/T the fear of failure AEB not seeking employment D.Chronic low self-esteem R/T major depressive disorder AEB self-hatred

Answer 25

C

Question 26

During an intake interview, which question would assist the nurse in gathering data about the client’s judgment? A.“What brought you to the hospital? Do you know what day and season it is now?” B.“On a scale of 1 to 10, how would you rate your stress level?” C.“What does the phrase ‘a rolling stone gathers no moss’ mean to you?” D.“If you found a stamped, addressed envelope in the street, what would you do?”

Answer 26

D

Question 27

An adolescent client has problems expressing anger appropriately. Which nursing statement would encourage the client to set realistic goals? A.“What do you think needs to change about how you express anger?” B.“How did you feel after attending the anger management session?” C.“On a scale of 1 to 10, please rate your current level of anger.” D.“What bothers you about the actions of others when you get angry?”

Answer 27

A

Question 28

The nurse interviewed a client who was uncooperative, answered questions with minimal responses, and rarely made eye contact. Which is the most complete documentation of baseline data obtained during the interview? A.“Appears uncooperative. Exhibits characteristics of depression.” B.“Maintains poor eye contact throughout interview process. Unable to answer interview questions due to depression.” C.“States, ‘I don’t need to be here.’ when discussing admission status. Maintains minimal eye contact and offers little data related to triggers for admission.” D.“Unwilling to respond openly during interview.”

Answer 28

C

Question 29

A client is assigned the nursing diagnosis of impaired social interaction R/T socio-cultural differences AEB client stating, “Although I’d like to, I don’t join in because I don’t speak the language so good.” Which correctly written outcome addresses this client’s problem? A.The client will collaborate with nursing staff to set specific goals by day 3. B.The client will participate in one group activity of choice by day 2. C.The client will express a desire to interact with others. D.The client will become increasingly independent by discharge.

Answer 29

B

Question 30

The following clients are seen in the emergency department. The psychiatric unit has one remaining bed. The triage nurse should expect which client to be admitted? A.The client who is experiencing tremors and has a need for medication adjustment B.The client who is experiencing anxiety and a sad mood after separation from spouse C.The client who is a single parent and hears voices stating, “Kill your infant son” D.The client who argued with her boyfriend and inflicted a superficial cut on her arm

Answer 30

C