Mental Health Ch. 5, 9, 21 Exercise Questions – Flashcards

According to the American Nurses Association (ANA) standards of practice for psychiatric mental health nurses, which specific intervention can be implemented by a psychiatric mental health nurse generalist? A. Milieu therapy B. Psychotherapy C. Consultation D. Prescriptive authority

Which nursing diagnosis is written correctly? A. Risk for social isolation related to low self-esteem evidenced by staying in room during the day. B. Low self-esteem related to major depressive disorder evidenced by childhood abuse. C. Imbalanced nutrition: less than body requirements related to suspiciousness evidenced by 20 lb. weight loss. D. Conduct disorder related to childhood sexual abuse evidence by hostile and aggressive behaviors.

Which charting entry is an example of documentation of a subjective symptom? A. Temperature 101.4 degrees F B. No muscle rigidity or drooling noted C. Client is hypervigilant and scanning the environment D. Client states, "I'm seeing green men in my room."

The nurse is using nursing process to care for a suicidal client. Which of the following nursing actions is a part of the assessment step of the nursing process? A.Identifies nursing diagnosis: Risk for suicide. B.Notes that client's family reports recent suicide attempt. C.Prioritizes the necessity for maintaining a safe environment for the client. D.Obtains a short-term contract from the client to seek out staff if feeling suicidal.

The nurse is using nursing process to care for a suicidal client. Which of the following nursing actions is a part of the diagnosis step of the nursing process? A.Identifies nursing diagnosis: Risk for suicide. B.Notes that client's family reports recent suicide attempt. C.Prioritizes the necessity for maintaining a safe environment for the client. D.Obtains a short-term contract from the client to seek out staff if feeling suicidal.

The nurse is using nursing process to care for a suicidal client. Which of the following nursing actions is a part of the outcome identification step of the nursing process? A.Prioritizes the necessity for maintaining a safe environment for the client. B.Determines if nursing interventions have been appropriate to achieve desired results. C.Obtains a short-term contract from the client to seek out staff if feeling suicidal. D.Establishes goal of care: Client will not harm self during hospitalization.

The nurse is using nursing process to care for a suicidal client. Which of the following nursing actions is a part of the planning step of the nursing process? A.Prioritizes the necessity for maintaining a safe environment for the client. B.Determines if nursing interventions have been appropriate to achieve desired results. C.Obtains a short-term contract from the client to seek out staff if feeling suicidal. D.Establishes goal of care: Client will not harm self during hospitalization.

The nurse is using nursing process to care for a suicidal client. Which of the following nursing actions is a part of the implementation step of the nursing process? A. Prioritizes the necessity for maintaining a safe environment for the client. B. Determines if nursing interventions have been appropriate to achieve desired results. C. Obtains a short-term contract from the client to seek out staff if feeling suicidal. D. Establishes goal of care: Client will not harm self during hospitalization.

The nurse is using nursing process to care for a suicidal client. Which of the following nursing actions is a part of the evaluation step of the nursing process? A. Prioritizes the necessity for maintaining a safe environment for the client. B. Determines if nursing interventions have been appropriate to achieve desired results. C. Obtains a short-term contract from the client to seek out staff if feeling suicidal. D. Establishes goal of care: Client will not harm self during hospitalization.

S.T. is a 15-year-old girl who has just been admitted to the adolescent psychiatric unit with a diagnosis of anorexia nervosa. She is 5 ft. 5 in. tall and weighs 82 lb. She was elected to the cheerleading squad for the fall but states that she is not as good as the others on the squad. The treatment team has identified the following problems: refusal to eat, occasional purging, refusing to interact with staff and peers, and fear of failure. Which of the following nursing diagnoses would be appropriate for S.T.?(Select all that apply.) A. Social Isolation B. Disturbed Body Image C. Low Self-Esteem D. Imbalanced Nutrition: Less than body requirements

S.T. is a 15-year-old girl who has just been admitted to the adolescent psychiatric unit with a diagnosis of anorexia nervosa. She is 5 ft. 5 in. tall and weighs 82 lb. She was elected to the cheerleading squad for the fall but states that she is not as good as the others on the squad. The treatment team has identified the following problems: refusal to eat, occasional purging, refusing to interact with staff and peers, and fear of failure. Which of the following nursing diagnoses would be the priority diagnosis for S.T.? A. Social Isolation B. Disturbed Body Image C. Low Self-Esteem D. Imbalanced Nutrition: Less than body requirements

Nursing diagnoses are prioritized according to: A. Degree of potential for resolution B. Legal implications associated with nursing intervention C. Life-threatening potential D. Client and family requests

Which of the following describe advantages to electronic health records (EHRs)? (Select all that apply.) A. They reduce redundancy of information. B. They reduce issues regarding privacy. C. They decrease charting time. D. They facilitate communication between disciplines.

An operating room nurse asks a psychiatric nurse, "How can you work with the mentally ill day in and day out?" the psychiatric nurse replies, "it's just the right thing to do." The psychiatric nurse is operating from which ethical framework? A. Kantianism B. Christian ethics C. Ethical egoism D. Utilitarianism

As a last report, an agitated, physically aggressive client is placed in four-point restraints. The client yells, "I'll sue you for assault and battery." The unit manager determines that the nurses are protected under which condition? A. The client is voluntary committed and poses as a danger to others on the unit. B. The client is voluntary committed and has a history of being a danger to others. C. The client is involuntary committed because of a history of violent behavior. D. The client is involuntary committed and is refusing treatment.

A nurse gave a client 5 mg of haloperidol (Haldol) for agitation. The client's chart was clearly stamped "Allergic HALDOL." The client suffered anaphylactic shock and died. How would the nurse's action be labeled? A. Intentional tort B. Negligence C. Battery D. Assault

Nurse Jones decides to go against family wishes and tell the client of his terminal status because that is what she would want if she were the client. Which of the following ethical theories is considered in this decision? A. Kantianism B. Christian ethics C. Natural law theories D. Ethical egoism

Nurse Jones decides to respect family wishes and not tell the client of his terminal status because that would bring the most happiness to the most people. Which of the following ethical theories is considered in this decision? A. Utilitarianism B. Kantianism C. Christian ethics D. Ethical egoism

Nurse Jones decides to tell the client of his terminal status because she believes it is her duty to do so. Which of the following ethical theories is considered in this decision? A. Natural law theories B. Ethical egoism C. Kantianism D. Utilitarianism

The nurse assists the physician with electroconvulsive therapy on his client who has refused to give consent. With which of the following legal actions might the nurse be charged because of this nursing action? A. Assault B. Battery C. False imprisonment D. Breach of confidentiality

A competent, voluntary client has stated he wants to leave the hospital. The nurse hides his clothes in an effort to keep him from leaving. With which of the following legal actions might the nurse be charged because of this nursing action? A. Assault B. Battery C. False imprisonment D. Breach of confidentiality

Joe is very restless and is pacing a lot. The nurse says to Joe, "If you don't sit down in the chair and be still, I'm going to put you in restraints!" With which of the following legal actions might the nurse be charged because of this nursing action? A. Defamation of character B. Battery C. Breach of confidentiality D. Assault

For which of the following reasons may an individual be considered gravely disabled ? (Select all that apply.) A. A person, because of mental illness, cannot fulfill basic needs. B. A mentally ill person is in danger of physical harm based on inability to care for self. C. A mentally ill person lacks the resources to provide the necessities of life. D. A mentally ill person is unable to make use of available resources to meet daily living requirements.

Which of the following statements is (are) correct regarding the use of restraints? (Select all that apply.) A. Restraints may never be initiated without a physician's order. B. Orders for restraints must be reissued by a physician every 2 hours for children and adolescents. C. Clients in restraints must be observed and assessed every hour for issues regarding circulation, nutrition, respiration, hydration, and elimination. D. An in-person evaluation must be conducted within 1 hour of initiating restraints.

Guidelines relating to "duty to warn" state that a therapist should consider taking action to warn a third party when his or her client: (Select all that apply.) A. Threatens violence toward another individual B. Identifies a specific intended victim C. Is having command hallucinations D. Reveals paranoid delusions about another individual

Attempting to calm an angry client by using "talk therapy" is an example of which of the following clients' rights? A. The right to privacy B. The right to refuse medication C. The right to the least-restrictive treatment alternative D. The right to confidentiality

The nurse is assisting a client with mental illness recovery using the WRAP model. Which of the following interventions would be included? A. Assisting the individual to tell his personal story B. Helping the client examine his philosophy of life in search of meaning and purpose C. Taking control of the recovery process for the client D. Helping the client craft a psychiatric advanced directive for when he can no longer care for himself.

Which of the following is a true statement about mental health recovery? (Select all that apply.) A. Mental health recovery applies only to severe and persistent mental illnesses. B. Mental health recovery serves to provide empowerment to the client. C. Mental health recovery is based on the medical model. D. Mental health recovery is a collaborative process.

A nurse is assisting an individual with mental illness recovery using the Tidal Model. Which of the following is a component of this model? A. The wellness toolbox B. The daily maintenance list C. The individual's personal story D. Triggers

A nurse is assisting an individual with mental illness recovery using the Psychological Recovery Model. The client says to the nurse, "I have schizophrenia. Nothing can be done. I might as well die." In which stage of the Psychological Recovery Model would the nurse assess this individual to be? A. The awareness stage B. The preparation stage C. The rebuilding stage D. The moratorium stage

A nurse who is helping a client in the preparation stage of the Psychological Recovery Model might include which of the following interventions? A. Teach about effects of the illness and how to recognize, monitor, and manage symptoms. B. Help the client identify "triggers" that cause distress or discomfort. C. Help the client establish a daily maintenance list. D. Listen actively while the client composes his or her personal story.

A nurse who is helping a client with mental illness recovery using the WRAP Model says to the client, "First you must create a wellness toolbox." She explains to the client that a wellness toolbox is which of the following? A. A list of words that describe how the individual feels when he or she is feeling well B. A list of things the client needs to do every day to maintain wellness C. A list of strategies the client has used in the past that help relieve disturbing symptoms D. A list of the client's favorite health-care providers and phone numbers