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

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

Answer 1

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

Answer 2

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.

Answer 3

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

Answer 4

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.

Answer 5

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

Answer 6

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

Answer 7

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.

Answer 8

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

Answer 9

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.

Answer 10

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

Answer 11

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.”

Answer 12

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

Answer 13

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.

Answer 14

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

Answer 15

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.

Question 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 your 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.”

Answer 16

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.

Question 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?”

Answer 17

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

Question 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. Which of the following questions would be appropriate for the nurse to ask?

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?”

Answer 18

ANS: A
The patient’s behaviours 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.

Question 19

At what point in an assessment interview would a nurse ask, “How does your faith help you in stressful situations?”

a. During the assessment of childhood growth and development
b. During the assessment of substance use and abuse
c. During the assessment of educational background
d. During the assessment of coping strategies

Answer 19

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.

Question 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 which of the following?

a. Counselling
b. Health teaching
c. Milieu management
d. Psychobiological intervention

Answer 20

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. Counselling 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.

Question 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

Answer 21

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

Question 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. Social isolation
d. Powerlessness

Answer 22

ANS: C
A nursing diagnosis is a clinical judgement about a patient’s response, needs, actual and potential psychiatric disorders, mental health problems, and potential co-morbid physical illnesses. A well-chosen and well-stated nursing diagnosis is the basis for selecting therapeutic outcomes and interventions. In this instance, the evidence shows social isolation that is caused by shyness and poorly developed social skills.

Question 23

What does the nurse assess when completing the final “S” of the HEADSSS Psychosocial Interview Technique?

a. Suicide risk
b. Savagery
c. Sexuality
d. Social support

Answer 23

ANS: B
The final S in the HEADSSS Psychosocial Interview Technique is to assess savagery, that is, violence or abuse in the home environment or neighbourhood.

Question 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
b. Decisional conflict
c. Risk for other-directed violence
d. Impaired verbal communication

Answer 24

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

Question 25

A nurse prepares to assess a new patient who moved to Canada from Central America three years ago. After introductions, what is the nurse’s next comment?

a. “How did you get to Canada?”
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?”

Answer 25

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.

Question 26

The nurse records this entry in a patient’s progress notes:
Patient escorted to unit by ER nurse at 2130. Patient’s clothing was dirty. In interview room, patient sat with hands over face, sobbing softly. Did not acknowledge nurse or reply to questions. After several minutes, abruptly arose, ran to window, and pounded. Shouted repeatedly, “Let me out of here.” Verbal intervention unsuccessful. Order for stat dose 2 mg haloperidol PO obtained; medication administered at 2150. By 2215, patient stopped shouting and returned to sit wordlessly in chair. Patient placed on one-to-one observation.
How should this documentation be evaluated?
a. Uses unapproved abbreviations
b. Contains subjective material
c. Too brief to be of value
d. Excessively wordy
e. Meets standards

Answer 26

ANS: E
This narrative note describes patient appearance, behaviour, and conversation. It mentions that less-restrictive measures were attempted before administering medication and documents patient response to medication. This note would probably meet standards. A complete nursing assessment would be in order as soon as the patient is able to participate. Subjective material is absent from the note. Abbreviations are acceptable.

Question 27

A nurse assessed a patient who reluctantly participated in activities, answered questions with minimal responses, and rarely made eye contact. What information should be included when documenting the assessment? Select all that apply.

a. The patient was uncooperative
b. The patient’s subjective responses
c. Only data obtained from the patient’s verbal responses
d. A description of the patient’s behaviour during the interview
e. Analysis of why the patient was unresponsive during the interview

Answer 27

ANS: B, D
Both content and process of the interview should be documented. Providing only the patient’s verbal responses would create a skewed picture of the patient. Writing that the patient was uncooperative is subjectively worded. An objective description of patient behaviour would be preferable. Analysis of the reasons for the patient’s behaviour would be speculation, which is inappropriate.

Question 28

A nurse performing an assessment interview for a patient with a substance use 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)

Answer 28

ANS: A, B, E
Standardized scales are useful for obtaining data about substance use disorders. The ASI, B-DAST, and RAATE are scales related to substance abuse. AIMS assesses involuntary movements associated with antipsychotic medications. The CCSE assesses cognitive function.

Question 29

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

a. Medical judgements about the disorder
b. Unmet patient needs currently present
c. Goals and outcomes for the plan of care
d. Supporting data that validate the diagnoses
e. Probable causes that will be targets for nursing interventions

Answer 29

ANS: B, D, E

Nursing diagnoses focus on phenomena of concern to nurses rather than on medical diagnoses.

Question 30

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.”

Answer 30

ANS: B, C, E
During the assessment interview, the nurse should listen attentively and accept the patient’s statements in a nonjudgemental way. The psychosocial assessment collects information, in the patient’s own words, about what the patient’s chief complaint is that day. 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 development of trust between the nurse and patient.