Chapter 6: Psychological Context of Psychiatric Nursing Care

Question 1

1. A patient admitted for treatment of uncontrolled diabetes mellitus is withdrawn and tearful. The patient says, “I just want to be normal again.” The nurse determines there is a need for a psychiatric evaluation primarily to assist:
   a. the patient in verbalizing distress about the disease.
   b. in assessing the emotional factors affecting the patient’s present condition.
   c. in assessing priorities to be set for the patient’s overall nursing plan of care.
   d. the patient in emotionally accepting the chronic nature of the disease.

Answer 1

ANS: B
The primary purpose would be to assess emotional factors that may have an effect on the patient’s current condition. The patient has given clues to psychological distress. Holistic care requires the assessment of biological, psychological, and sociocultural health status.

Question 2

2. Success in obtaining sufficient data in the initial psychiatric interview depends largely on the:
   a. patient’s ability to communicate effectively.
   b. interviewer’s ability to establish good rapport.
   c. number of psychiatric interviews the nurse has performed.
   d. interviewer’s ability to organize and systematically record data.

Answer 2

ANS: B
Patients with whom the nurse has established rapport will feel understood by the examiner and will be more willing to cooperate with the examiner’s questions. Although the remaining options have an impact on the success of the interview, they are not the primary factor.

Question 3

3. A nurse plans to engage in participant observation while conducting a mental status examination. This will require the nurse to:
   a. increase verbalization with the patient.
   b. listen attentively to the patient’s response.
   c. engage in communication and observation simultaneously.
   d. advise the patient on what to do about data obtained during the interview.

Answer 3

ANS: C
Participant observation is a clinical approach that allows the nurse to critically observe a patient while structuring the examination in a way that allows for the broad exploration of many areas to screen for potential problems and for the in-depth exploration of obvious symptoms or maladaptive coping responses. Discussing treatment options is not the purpose of this intervention. Verbalization and attentive listening are required but may not need to be increased.

Question 4

4. A nurse conducting a mental status examination should plan to:
   a. compare results with at least one other nurse.
   b. perform the examination without the patient knowing.
   c. integrate the examination into the nursing assessment.
   d. perform the examination as the first communication with the patient.

Answer 4

ANS: C
Many observations can be made during other aspects of the nursing assessment, and specific questions can be blended into the general flow of the interview. Planning to compare results requires the assumption that more than one assessment will be conducted. This examination requires input from the patient that is best secured when the patient-nurse relationship has been established.

Question 5

5. A patient visiting from Puerto Rico has become psychotic while staying with family here in the United States. When conducting the mental status examination, the nurse remembers that:
   a. sociocultural factors may greatly affect the examination.
   b. liking the patient as a person is important to the outcome.
   c. an interpreter may help facilitate the verbal portion of the examination.
   d. biological expressions of psychiatric illness are not relevant to someone from another culture.

Answer 5

ANS: A
Dress, eye contact, personal hygiene, speech and use of language, personal space, and body language are a few aspects of the mental status examination that vary with culture and social status.

Question 6

6. A cognitively impaired patient reports to the nurse that, “I had the best time. My husband took me out to dinner and then to a concert. The music was wonderful.” Knowing that the patient is a widow, the nurse determines her remarks are an example of:
   a. tangential thinking.
   b. confabulation.
   c. hallucination.
   d. circumstantiality.

Answer 6

ANS: B

Confabulation means covering one’s inability to remember by making up a story of something that might have happened.

Question 7

7. A patient diagnosed with depression tells a nurse, “If I hadn’t been admitted, I would have carried out my plan and everyone would have been better off without me.” The nurse responds:
   a. “It’s frustrating when plans are interrupted.”
   b. “Things can still turn out all right for you while you’re here.”
   c. “What specifically did you plan to do before you were admitted?”
   d. “I know you’re feeling bad now but if you talk, things will be better.”

Answer 7

ANS: C
Suicidal intent should be openly and directly investigated. The other options either provide false hope or are not directed at the most serious patient issue.

Question 8

8. When asked what a mental status examination is intended to reveal about the patient, the nurse answers:
   a. “It gives us a more complete family history.”
   b. “It reflects the patient’s current state of function.”
   c. “It reveals a lot about the patient’s past experiences.”
   d. “It helps us determine the patient’s future prognosis.”

Answer 8

ANS: B
The mental status examination is designed to give a picture of the patient’s current level of functioning. The information provided may be a factor in prognosis, but that is not the primary function of the examination. Family history and general patient information are derived from other sources and the general nursing interview.

Question 9

9. A nurse will perform a mental status examination. The data most pertinent for determining the patient’s affective response will be the patient’s:
   a. judgment and insight.
   b. sensorium and memory.
   c. appearance and thought content.
   d. statements of mood and affect.

Answer 9

ANS: D
Mood is the patient’s self-report of his or her prevailing emotional/affective state. The remaining options are more related to cognition and thought.

Question 10

10. Which clinical skills used to conduct a mental status examination are most relevant to establishing rapport?
    a. Clarification and restatement
    b. Information giving and feedback
    c. Systematic inquiry and organization of data
    d. Attentive listening, observation, and focused questions

Answer 10

ANS: D
Attentive listening, observation, and focused questions allow for the use of empathic statements and make a patient feel understood, which fosters rapport. The other options are broadly related to communication in general.

Question 11

11. The health care provider describes a patient as being dressed like a “typical patient with mania.” From this statement, the nurse can assume that the patient’s mode of dress was:
    a. drab.
    b. slovenly.
    c. seductive.
    d. flamboyant.

Answer 11

ANS: D
Patients with mania often dress in bright colors and mix a variety of patterns. Their attire may give them an eccentric or bizarre look. “Drab” usually reflects more of a personal preference in dress, whereas “slovenly” and “seductive” may be considered indicators of mental illness if seen in combination with other specific assessment observations.

Question 12

12. Generally, a nurse can expect the motor activity of a patient with profound depression and the motor activity of a patient with mania to:
    a. be similar.
    b. show many tics and grimaces.
    c. be at opposite ends of the continuum.
    d. show unusual bizarre gestures or posturing.

Answer 12

ANS: C
Patients with mania show excessive body movement, whereas many patients with depression show little body activity. Tics and grimaces may be medication-related, whereas bizarre gesturing and posturing are not usually associated with mood disorders.

Question 13

13. The patient believes that the CIA is “plotting to kill me.” The report is given with the patient exhibiting little emotion. The nurse documents the patient’s affect as:
    a. flat.
    b. elated.
    c. labile.
    d. congruent.

Answer 13

ANS: A
Reporting significant life events with little emotional response suggests a blunted or flattened affect. Lability refers to swift shifts in affect. Congruent affect is appropriate emotional expression for the current circumstances. Elation is an exaggerated display of happiness. The patient is not showing fear or anxiety, which would be appropriate in this case, nor is the patient displaying exaggerated happiness, which would be inappropriate under the circumstances.

Question 14

14. During a mental status examination, a patient shouts angrily at the nurse, “You are too nosy for your own good!” Then, almost immediately, happily says, “Well, let’s let bygones be bygones and be buddies.” The nurse assesses this emotional display as:
    a. labile affect.
    b. hallucinations.
    c. magical thinking.
    d. ideas of reference.

Answer 14

ANS: A
Lability is identified when the patient’s affect shifts rapidly, such as from happy to sad or angry to elated. The remaining options are thought-content descriptors.

Question 15

15. To assess for the presence of hallucinations during the mental status examination, a nurse should ask:
    a. “Can you tell me what the name of this building is?”
    b. “Do you ever see or hear things that others don’t see or hear?”
    c. “When did you start believing aliens were controlling your thoughts?”
    d. “What do I mean when I say, ‘Don’t count your chickens before they hatch?’”

Answer 15

ANS: B
Hallucinations are false sensory perceptions while delusions are non-reality–based beliefs. The remaining options are related to thought or cognitive disorders.

Question 16

16. A patient tells a nurse, “God has given me special powers to heal the sick and raise the dead. I can cast out demons and cure cancer.” The nurse assesses the patient’s statements as indicating:
    a. a phobia.
    b. depersonalization.
    c. grandiose delusions.
    d. an idea of reference.

Answer 16

ANS: C
Grandiose delusions are beliefs that one possesses greatness or special powers. A phobia is a morbid fear, depersonalization is a loss of self-identity, and idea of reference is the incorrect interpretation of casual events.

Question 17

17. Which question would best assess a patient’s ability to make judgments?
    a. “Who is the president of the USA?”
    b. “How long have you been here?”
    c. “What is the name of the building we’re in?”
    d. “If you won $10,000, what would you do with it?”

Answer 17

ANS: D
The correct option involves judgment since it is asking what the patient would do with $10,000. The remaining options assess the patient’s orientation to self, time, and place.

Question 18

18. A nurse assessing a patient’s emotional intelligence will focus on the patient’s:
    a. linguistic and musical abilities.
    b. body kinesthetic and spatial abilities.
    c. interpersonal and intrapersonal skills.
    d. logical mathematics and linguistic abilities.

Answer 18

ANS: D

Interpersonal intelligence and intrapersonal intelligence form one’s personal intelligence or “emotional quotient.”

Question 19

19. A nurse asks a patient to remember the following object, color, and address: pencil, red, and 15 Maple Street. After 15 minutes the nurse asks the patient to repeat the object, color, and address. The nurse is assessing:
    a. judgment.
    b. recent memory.
    c. ability to abstract.
    d. immediate recall.

Answer 19

ANS: B
Recent memory is tested when the patient is asked to recall several words 15 minutes after hearing them for the first time.

Question 20

20. While interviewing a patient, a nurse notes that the patient uses invented words and that the patient’s thoughts do not seem to flow logically. These observations are most consistent with a diagnosis of:
    a. depression.
    b. panic disorder.
    c. schizophrenia.
    d. defensive coping.

Answer 20

ANS: C
These symptoms indicate the presence of a thought disorder seen more often in patients with schizophrenia than in those with panic or depression. Defensive coping is not a diagnosis.

Question 21

21. To gather data about a patient’s judgment, which question would be most appropriate?
    a. “What brought you to the hospital?”
    b. “On a scale of 1 to 100, what would you consider your stress level to be?”
    c. “What problem would you like to work on while you are hospitalized?”
    d. “If you found a stamped, addressed envelope lying in the street, what would you do with it?”

Answer 21

ANS: D
Judgment involves making decisions that are constructive and adaptive. The other options relate information but do not require critical thinking to produce a judgment.

Question 22

22. The Mini-Mental State Examination would be used by a nurse who is interested in obtaining information about:
    a. affect changes.
    b. cognitive processes.
    c. thought content and processes.
    d. abnormal psychological experiences.

Answer 22

ANS: B
The Mini-Mental State Examination is a simplified scored form of the cognitive mental status examination. It consists of 11 questions, including “what is today’s date?”, “what month is it?”, and “where are you right now?”, and it requires only 10 minutes to administer.

Question 23

23. Asking a patient to give the meaning of the proverb “people who live in glass houses shouldn’t throw stones” will assist a nurse in assessing the patient’s:
    a. short-term memory.
    b. orientation to reality.
    c. emotional intelligence.
    d. ability to think abstractly.

Answer 23

ANS: D
Interpreting proverbs gives clues to the patient’s ability to move from concrete to abstract thinking by stating meaning in terms symbolic of human behavior or events.

Question 24

24. During a mental status examination, a patient sits looking tense and suspicious. The patient has a reddened scar on the left cheek and is wearing a torn, soiled shirt and only one shoe. Which observation about appearance has the greatest significance for the patient’s current mental state?
    a. The patient has a reddened scar on the left cheek.
    b. The patient is wearing a torn, soiled shirt.
    c. The patient appears tense and suspicious.
    d. The patient is wearing only one shoe.

Answer 24

ANS: C
The observation of tension and suspicion indicates current stress and possible paranoia. The scar, the condition of the clothing, and the absence of a shoe are not as relevant to the patient’s current mental state because they originated in a time other than the present.

Question 25

25. During an interview, a patient with mania demonstrates very rapid speech and talks continuously and loudly. The patient’s speech pattern is best documented as:
    a. tangential.
    b. pressured.
    c. inappropriate.
    d. circumlocution.

Answer 25

ANS: B

Pressured speech is rapid, forcefully delivered speech that is often loud and excessive.

Question 26

26. While being interviewed, a patient expresses the belief that other people can place beliefs in her mind. This statement can be assessed as evidence of:
    a. thought insertion.
    b. nihilistic delusions.
    c. somatic delusions.
    d. ideas of reference.

Answer 26

ANS: A

Thought insertion is the delusion that thoughts are placed into the mind by people or influences outside of the self.

Question 27

27. During a mental status evaluation, a nurse’s intuition may indicate:
    a. clues about the patient’s physical well-being.
    b. subtle emotions being expressed by the patient.
    c. areas to be explored in the predischarge interview.
    d. potential nursing diagnoses that relate to a patient knowledge deficit.

Answer 27

ANS: B
Subtle emotions are transmitted during the mental status evaluation, but they may register only as suspicions. Examples are subtle hostility that may make the nurse feel threatened or angry and sadness or hopelessness that may make the nurse feel sad.

Question 28

MULTIPLE RESPONSE

1. A nurse managing the care of a depressed patient will use the Beck Depression Inventory Scale at admission and during the course of treatment. The nurse expects to obtain assessment data that would: (Select all that apply.)
   a. confirm the patient’s diagnosis.
   b. measure the extent of the patient’s problem.
   c. identify co-morbid physiological disorders.
   d. track the patient’s progress over the hospitalization.
   e. predict the patient’s likelihood of experiencing a relapse.

Answer 28

ANS: A, B, D
This tool is not designed to predict the possibility/probability of relapse or identify co-morbid physiological disorders.