Chapter 10

Question 1

what is the nursing process?
think of the anagram

Answer 1

ADIPE

assessment
diagnosis
planning
implementation
evaluation

Question 2

what is the assessment in psychiatric mental health ?

Answer 2

deliberate and systematic collection of information or data to determine current and past health, mental health, wellness, strengths, functional status, and present and past coping patterns

Question 3

the assessment always begins with obtaining a what?

Answer 3

chief complaint

Question 4

during your assessment of a patient, you may ask what?

Answer 4

direct or indirect questions

Question 5

what does the assessment of the physical domain include ?
dont over think it

Answer 5

current and past health status
physical examination of body systems
review of physical functions
pharmacologic
strength
wellness assessment

Question 6

what are the 4 psychological assessments we are going to do for our patient ?

Answer 6

mental health problems
mental status examination
behavior responses
risk factor assessment

Question 7

how are mental health problems assessed in a patient ?

Answer 7

identifiy any mental health disorders and their current strategies or behaviors in dealing with that disorder

Question 8

how are behavior responses assessed in a patient ?

Answer 8

current and past patterns
and
how the patient views self

Question 9

how do we assess risk factors in patients ?

Answer 9

ascertaining weather the patient has any suicidal, assaultive or homicidal ideation

Question 10

when doing a mental status examination on a patient, how does it help us as nurses? (2)

Answer 10

establish a baseline of where the patient is currently at

creates a written record/ documentation

Question 11

the mental status examination includes? (11)

Answer 11

general observations of apperance

psychomotor activity & attitude

orientation

mood and affect

emotions

speech

thought process

attention and concentration

abstract reasoning and comprehension

memory

insight and judgment

Question 12

how are we assessing their general observations?

Answer 12

physical - underweight, overweight
dressing
behavior - guarded, irritable

Question 13

what is the difference between mood and affect?

Answer 13

mood - the person feels

affect - how you think the person feels

Question 14

how do we assess patients for speech ?

Answer 14

fruit salad, slowness, talking nonstop, skipping words, slurred

Question 15

how do we assess a patient thought process?

Answer 15

delusional, hallucinations, illusion, psychotic

Question 16

how do we assess a patients attention and concentration ?

Answer 16

are they focused, distracted

Question 17

how do we assess abstract and comprehension ?

Answer 17

they can’t think outside of a metaphor, like giving them a metaphor and they can’t describe it

Question 18

how do we assess memory?

Answer 18

ask a random question at the start of the assessment then re ask at the end

Question 19

how do we assess insight and judgment?

Answer 19

their ability to recognize their own mental illness and their part in it

making good choices for themselves

Question 20

what are some social assessments we are going to need to ask or find out ?
dont over think it

Answer 20

functional status
social systems
spirtuality
occupational, economic, legal status

Question 21

the nursing assessment should provide data for nursing diagnoses and planning with the patient for mutually agreeable outcomes

• anticipated patient outcomes provide direction for psychiatric - mental health nursing interventions

Question 22

what are some examples of biologic nursing interventions ?

Answer 22

self care
sleep
nutrition

Question 23

what are some examples psychological nursing interventions ?

Answer 23

behavior therapy
counseling
health teaching

Question 24

what are some examples of social nursing interventions ?

Answer 24

community and home interventions
milieu therapy

Question 25

evaluation of patient outcomes involves what 3 things?

Answer 25

cost-effectiveness
benefit to the patient
patients level of satisfaction

Question 26

how should outcomes be measured after an interventions is performed?

Answer 26

immediately
or after some Time passes

Question 27

chapter 10 : the psychiatric- mental health nursing process part 2
risk assessment

Question 28

when it comes to risk assessment we usually like to give two main categories, suicide and homicide. however the questions are going to be the same

the following are the 5 main questions we are going to ask patients and document when assessing their risk of suicide or homicide

what is ideation mean ?
what is plan mean?
what is means mean?
what is intent/prepartion mean?
what is history mean ?

Answer 28

do you have these thoughts ?
do you have a plan to do this?
can you get the materials do to this?
do you want to carry this out, do you have this prepared ?
have you done this before, how lethal was the attempt before ?

Question 29

in suicide, you have an active and passive, can you describe each ?

Answer 29

active suicide
- you are actively thinking about suicide

passive suicide
- “just like to die”
- “family better off without me”

Question 30

when a patient has homicidal thoughts you as a nurse have the responsibility to what?

Answer 30

duty to warn!

inform the people around and the person who is going to die

Question 31

for suicide risk factors, you have two forms, which are ?

Answer 31

acute ( modifiable )
chronic ( static )

Question 32

what is acute modifiable suicide risk factors?

Answer 32

anxiety, impulsivity, substance use, self-injurious behaviors, stress

Question 33

what is chronic (static) suicide risk factors?

Answer 33

previous suicide attempt
age, gender
chronic medical problems
family history of suicide attempt
psych illness

Question 34

its also very important to try to help mitigate risk factors, how can we do this or assess for this ?

Answer 34

no previous history
denies si
no alcohol
no weapon in the home
absence of mental health illness
develop crisis response plan

Question 35

questions 1
A 36-year-old patient with a diagnosis of depression who has attempted suicide says to the nurse, “I should have died. I’ve always been a failure. Nothing ever goes right for me.” Which response by the nurse demonstrates therapeutic communication?

A. “You have everything to live for.”

B. “Why do you see yourself as a failure?”

C. “Feeling like this is all part of being depressed.”

D. “So have you been feeling like a failure for a while?”

Answer 35

D. “So have you been feeling like a failure for a while?”

Question 36

question 2
The nurse visits a patient at home. The patient states, “I haven’t slept at all the last couple of nights.” Which response by the nurse demonstrates therapeutic communication?

A. “I see.”
B. “Really?”
C. “You’re having difficulty sleeping?”
D. “Sometimes I have trouble sleeping too.”

Answer 36

C. “You’re having difficulty sleeping?”

Question 37

Question 3
A 19-year-old patient experiencing disturbed thought processes
believes that his food is being poisoned. Which communication technique should the nurse use to encourage the patient to eat?

A. Using open-ended questions and silence

B. Sharing personal preference regarding food choices

C. Documenting reasons why the client does not want to eat

D. Offering opinions about the necessity of adequate nutrition

Answer 37

A. Using open-ended questions and silence

Question 38

question 4
A 57-year-old high school teacher diagnosed with terminal cancer says to the nurse, “I’m going to die, and I wish my family would stop hoping for a cure! I get so angry when they carry on like this. After all, I’m the one who’s dying.” Which response by the nurse is therapeutic?

A. “Have you shared your feelings with your family?”

B. “I think we should talk more about your anger with your family.”

C. “You’re feeling angry that your family continues to hope for you to be cured?”

D. “You are probably very depressed, which is understandable with such a diagnosis.”

Answer 38

C. “You’re feeling angry that your family continues to hope for you to be cured?”