Chapter.9 Flashcards
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
C
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.
B
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
B
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.
D
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.
C
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
B
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
D
The nurse should recognize which acronym as representing problem-oriented charting?
A.SOAPIE
B.APIE
C.DAR
D.PQRST
A
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
C
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
C
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.
B
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
C
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
A
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
B
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.
C