Question 1

What is the nurse’s primary source for data collection? a. The patient b. The patients chart c. The admission history and physical d. The patient’s family or significant other

Accepted Answer

ANS: A The nurse’s primary source of data is the patient; however, there may be times when it is necessary to supplement or rely completely on another for the assessment information. These secondary sources can be invaluable when caring for a patient experiencing psychosis, muteness, agitation, or catatonia. Such secondary sources may include members of the family, friends, neighbours, police, health care workers, and medical records.

Question 2

A newly admitted patient diagnosed with major depression has gained 10 kilograms 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

Accepted Answer

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.

Question 3

A patient diagnosed with major depression has lost 9 kilograms 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.

Accepted Answer

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.

Question 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 which of the following? a. Consistently met b. Often met c. Sometimes met d. Unmet

Accepted Answer

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 unmet.

Question 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.

Accepted Answer

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 having time for 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.

Question 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. Implementation d. Evaluation

Accepted Answer

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

Question 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 do which of the following? 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

Accepted Answer

ANS: B Assessment should include data obtained from both the primary and reliable secondary sources. To gain an even clearer understanding of your patient, it is helpful to look to outside sources for information.

Question 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.

Accepted Answer

``` 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. ```

Question 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

Accepted Answer

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 needs to initiate suicide precautions (e.g., ongoing observations and monitoring of the patient, provision of a protective environment) for the person who is at serious risk for suicide. 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.

Question 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.” a. Patient will show improved use of language. b. Patient will demonstrate improved social skills. c. Patient will become more independent in decision making. d. Patient will select and participate in one group activity per day.

Accepted Answer

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.

Question 11

Nursing behaviours associated with the implementation phase of nursing process are concerned with which of the following? a. Participating in mutual identification of patient outcomes b. Gathering accurate and sufficient patient-centred data c. Comparing patient responses and expected outcomes d. Carrying out interventions and coordinating care

Accepted Answer

ANS: D The psychiatric mental health nurse coordinates the implementation of the plan and provides documentation. Some registered nurses and registered psychiatric nurses are educationally and clinically prepared to conduct advanced interventions such as offering psychotherapy to individuals, couples, groups, and families and providing consultation to other disciplines using evidence-informed psychotherapeutic frameworks and nurse–patient therapeutic relationships.

Question 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.”

Accepted Answer

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

Question 13

Who is the best person to provide information about a 4-year-old’s behaviour, attitude, and performance? a. The child b. The parent(s) c. The family doctor d. The psychologist

Accepted Answer

ANS: B When assessing children, it is important to gather data from a variety of sources. Although the child is the best source for determining emotions, the caregivers (parents or guardians) often can best describe the behaviour, performance, and attitude of the child. Caregivers also are helpful in interpreting the child’s words and responses.

Question 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.

Accepted Answer

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.

Question 15

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

Accepted Answer

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

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Chapter 09: The Nursing Process and Standards of Care for Psychiatric Mental Health Nursing Flashcards

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