Mental Health Chapter 7 and ATI Chapter 1 – Flashcards
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In psychiatric nursing, assessment of a "client" refers exclusively to an individual, family, group, or community.
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an individual, family, group, or community. Correct Standards of practice for psychiatric nursing indicate that the client can be an individual, a family, a group, or a community.
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High levels of anxiety and maladaptive behavior are seen in all areas in the health care setting.
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in all areas in the health care setting. Correct Anxiety occurs whenever individuals are faced with unfamiliar circumstances or other threats to the self. The health care setting presents many possible threats to the self, such as illness, disability, surgery, and pain.
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Which activity is NOT considered a purpose of the initial psychiatric assessment? Evaluating the results of intervention
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Evaluating the results of intervention Correct At an initial assessment, no interventions would have taken place; hence evaluation is not a purpose of the initial contact.
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The primary source for data collection during a psychiatric nursing assessment is the client's own words and actions.
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client's own words and actions. Correct The client should always be considered the primary data source. At times, however, the client will be unable to fulfill this role
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The nurse best ensures appropriate client care when choosing an intervention from a Nursing Interventions Classification that matches both the defining data and the nursing diagnosis.
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the defining data and the nursing diagnosis. Correct When choosing nursing interventions from the Nursing Interventions Classification or some other source, the nurse selects interventions that fit the nursing diagnosis (e.g., risk for suicide) and that match the defining data.
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During the initial assessment interview with a psychiatric client, the nurse should regard the spiritual assessment as important to complete.
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important to complete. Correct For many clients, religious or spiritual practices are an important part of the quality of their lives. Nurses should support the spiritual dimension of the person. To do so, assessment is necessary.
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What three structural components comprise a nursing diagnosis? Problem, etiology, supporting data
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Problem, etiology, supporting data Correct
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A tool the novice nurse might refer to when writing treatment results criteria is th Nursing Outcomes Classification (NOC).
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Nursing Outcomes Classification (NOC). Correct The Nursing Outcomes Classification is a publication used as a resource across the United States.
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Which criterion is NOT essential when the nurse plans nursing interventions designed to meet a specific goal? Economic
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Economical Correct Although expense should be considered, interventions are chosen based on the other options and not on their economic value.
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The mental status examination aids in the collection of what type of data? Objective
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Objective Correct The mental status exam mostly aids in the collection of objective data.
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the principle that is the basis of nursing outcome planning is individuals have the right to autonomy to make decisions that affect them.
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individuals have the right to autonomy to make decisions that affect them. Correct This is the only true statement. The nurse and the client should work collaboratively because each has knowledge to contribute to planning for the attainment of mutually derived outcomes. REF: Page 124-125
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Interviewer anxiety during an assessment interview is most likely to be a result of the client's perception of the interviewer's ability to help.
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the client's perception of the interviewer's ability to help. Correct Whenever a client is in doubt about the helpfulness of the interviewer, anxiety is generated. The interviewer can "tune in" to the client's anxiety by empathy. REF: Page 116-117
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The most likely factor to interfere with data collection in an initial assessment interview of an older adult is whether the client has any physical deficiencies.
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whether the client has any physical deficiencies. Correct While all the options can interfere, the most prevalent one affecting the data collected is any physical and/or cognitive deficiencies that client may possess. REF: Page 122-123
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A nurse is interviewing a new client who is angry and highly suspicious. When asked about sexual orientation, the client becomes highly distressed and threatens to walk out of the interview. The nurse responds "I can see that this topic makes you uncomfortable. We can defer discussion of it today."
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"I can see that this topic makes you uncomfortable. We can defer discussion of it today." Correct A cardinal rule of interviewing is "Don't probe sensitive areas." Clients are allowed to take the lead. REF: Page 117-118
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A nurse is about to interview a client whose glasses and hearing aid were placed in safe-keeping when she was admitted. Before beginning the interview, the nursing intervention that will best facilitate data collection is to assist the client in putting on glasses and hearing aid.
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assist the client in putting on glasses and hearing aid. Correct A client whose hearing or sight is impaired may have difficulty providing information if these items have been removed from his or her possession. Assisting the client in wearing these assistive devices is the best initial intervention. REF: Page 118-119
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What is the common behavior shared by both client and nurse at the beginning of the initial assessment interview? Anxiety
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Anxiety Correct Both parties feel at least a small amount of anxiety associated with interacting with an unknown person. REF: Page 117-118
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When interviewing an adolescent client, the nurse can expect the client to be most concerned about the issue of confidentiality.
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confidentiality. Correct Adolescents are often concerned that what they reveal to the nurse or health care team will be shared with parents. Confidentiality should be explained at the outset of the interview.REF: Page 118
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The nurse best assesses the client's spiritual life by asking, "What role does religion play in your life?"
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"What role does religion play in your life?" Correct Asking the client to define the role of religion in their life allows for discussion related to the other topics. REF: Page 121-122
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Which nursing diagnosis for a psychiatric client is correctly structured and worded? Imbalanced nutrition: less than body requirements related to poor self-concept as evidenced by reporting "I'm not worthy of eating"
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Imbalanced nutrition: less than body requirements related to poor self-concept as evidenced by reporting "I'm not worthy of eating" Correct This diagnosis contains all the required components: problem statement, the etiology, and supporting data. REF: Page 123
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The client's priority nursing diagnosis has been established as risk for self-directed violence: suicide related to multiple losses. The priority outcome would be that the client will refrain from attempting suicide.
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refrain from attempting suicide. Correct Refraining from suicidal attempts is the only outcome that addresses the risk for self-directed violence. The absence of a feeling of powerlessness is not appropriate for the stated nursing diagnosis. The remaining options are interventions. REF: Page 124-125
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You are conducting an admission interview with Callie, who was raped 2 weeks ago. When you ask Callie about the rape, she becomes very anxious and upset and begins to sob. Your best course of actions would be to: acknowledge that the topic of the rape is upsetting to Callie and reassure her that it can be discussed at another time when she feels more comfortable.
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acknowledge that the topic of the rape is upsetting to Callie and reassure her that it can be discussed at another time when she feels more comfortable. Correct The best atmosphere for conducting an assessment is one with minimal anxiety on the patient's part. If a topic causes distress, it is best to abandon the topic at that time. It is important not to pry or push for information that is difficult for the patient to discuss. The use of silence continues to expect the patient to discuss the topic now. Reassurance of confidentiality continues to expect the patient to discuss the topic now.
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You are interviewing Jamie, a 17-year-old female patient. She confides that she has been thinking of ways to kill a female peer who is Jamie's rival for the volleyball team captain position. She asks you if you can keep it a secret. The most appropriate response for you to make is: "Jamie, issues of this kind have to be shared with the treatment team and your parents."
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"Jamie, issues of this kind have to be shared with the treatment team and your parents." Correct Although adolescent patients request confidentiality, issues of sexual abuse, threats of suicide or homicide, or issues that put the patient at risk for harm must be shared with the treatment team and the parents. A threat of this nature must be discussed with the treatment team and the parents. Confidentiality laws do not protect information that would lead to harm to the patient or others. This information would be shared with both the team and the parents
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Which response to a patient's question of why you need to conduct an assessment interview best explains its purpose? "We will be able to form a relationship together where we can discuss the current problems and come up with goals and a plan for treatment."
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"We will be able to form a relationship together where we can discuss the current problems and come up with goals and a plan for treatment." Correct Some of the purposes of the assessment interview are to establish rapport, learn more about the presenting issues, and form mutual goals and a plan for treatment. The other options do not appropriately explain the assessment purpose.
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Joel is a 43-year-old patient being seen in the mental health clinic with depression. Joel states, "I have always been a practicing Jew, but in the past few months I am questioning everything. I just don't know if I believe in it anymore." Which of the following nursing diagnoses best describes Joel's comment? Spiritual distress
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Spiritual distress Correct Joel is expressing distress regarding his religion and spiritual well-being. Joel could be experiencing ineffective coping, but this does not directly relate to his comment. There is nothing in Joel's comment that would lead to the conclusion the patient is having thoughts of harming himself. Joel's comment does not describe hopelessness.
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You are working in the emergency department when a 26-year-old male patient is brought in suffering from psychosis. The patient is unable to give any coherent history. The patient's best friend is with him and offers to give you information regarding the patient. Which of the following responses is appropriate? "Yes, I will be happy to get any information and history that you can provide."
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"Yes, I will be happy to get any information and history that you can provide." Correct The friend is a secondary source of information that will be helpful since the patient is not able to give any history or information at this time. Confidentiality laws do not prohibit obtaining information from a secondary source. The friend can provide information and/or history immediately and may be able to relate events that happened just before coming to the hospital. A release would not be necessary to take information about the patient from a secondary source, and a psychotic patient would not be competent to sign a release.
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While performing a mental status examination on a client, the nurse notices that the client's facial expression constantly appears angry. This information should be recorded as part of the client's C. affect.
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C. affect Description of the client's facial expression is described as affect. Facial expression is not described in the areas of behavior, appearance, or thought process.
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. During a mental status examination, a client who is hospitalized states that she is in the hospital "to help out with the other patients." The nurse should record this information as A. poor insight.
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A. poor insight. The nurse's objective assessment of the client's insight reflects the client's understanding of her current situation and medical condition. Knowledge, judgment, and memory are other objective cognitive assessments. None reflect the client's understanding of the responsibility for, or analysis of, the current situation.
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Which of the following are examples of subjective assessment data? (Select all that apply.) ● ● "Client states he has no reason to live." ● ● "Client meditates for relaxation." ● ● "Client states that he drinks three beers a day."
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Subjective data includes psychosocial information about the client's thoughts, actions and feelings that can only be described by the client. Objective data is based on observable or verifiable facts.
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A nurse is caring for a client diagnosed with paranoid schizophrenia, asthma, generalized anxiety disorder, and borderline personality disorder. Which of the following diagnoses should the nurse expect to find included in Axis II of this client's DSM-IV-TR axis diagnosis? D. Borderline personality disorder
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D. Borderline personality disorder Personality disorders and mental retardation are included in Axis II. Paranoid schizophrenia and generalized anxiety disorder are found in Axis I. Asthma and other general medical conditions are found in Axis III.
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A client is admitted to an acute care mental health facility. The following medical diagnoses and psychosocial information are available at the time of admission: hypothyroidism, mild mental retardation, bipolar I disorder. The client's highest level of functioning from a global assessment of functioning (GAF) performed a year ago was 45. Today, the highest level of functioning on the same scale is 15. The client has been fighting with other clients frequently at the group home. How should the nurse enter this information into the multiaxial system of the DSM- IV- TR? Axis I: Bipolar I disorder Axis II: Mild mental retardation Axis III: Hypothyroidism Axis IV: Has been fighting with other clients frequently at group home Axis V: GAF 15/45
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Axis I includes most mental health clinical disorders, except those placed on Axis II. Axis II disorders include personality disorders and mental retardation. Axis III includes general medical disorders and problems. Axis IV includes pertinent psychosocial information or problems with living conditions. Axis V includes GAF for present assessment and previous assessment within 1 year of present.
