Test 1 Practice Questions- Nursing Process in Psychiatric/Mental Health Nursing – Flashcards
Unlock all answers in this set
Unlock answersquestion
2. Orientation to place
answer
While evaluating the mental status of a client with schizophrenia, the nurse asks the client, "Where are you now?" What is the nurse trying to assess in the client? 1. Orientation to time 2. Orientation to place 3. Orientation to person 4. Orientation to situation
question
4. Ability to follow simple verbal commands
answer
The nurse instructs the client to tear a piece of paper in half and put it in the trash can. What is the nurse trying to evaluate in the client through this instruction? 1. Abstract thinking 2. Ability to concentrate 3. Understanding spatial relationships 4. Ability to follow simple verbal commands
question
3. "What does this mean: 'No use crying over spilled milk'?"
answer
The nurse is performing a brief mental status evaluation in a client with psychiatric illness. Which question should the nurse ask the client to assess abstract thinking? 1. "What year is it? What month is it? What day is it?" 2. "Repeat these words now: bell, book, and candle." 3. "What does this mean: 'No use crying over spilled milk'?" 4. "Tear this piece of paper in half and put it in the trash can."
question
1. Euphoria
answer
What information does the nurse find under the section "mood/affect" in the mental history form? 1. Euphoria 2. Obsessions 3. Projection 4. Acceptance
question
1. When the client experiences hallucinations
answer
When does a client with schizophrenia require risperidone therapy? 1. When the client experiences hallucinations 2. When the client expresses fear of failure 3. When the client has an unkempt appearance 4. When the client exhibits social withdrawal
question
1. Assessment
answer
A client with mental illness is admitted in the psychiatric unit. After admitting the client, the nurse interviews the client's family members, reviews the client's records, and performs a physical examination of the client. Which step of the nursing process do these nursing actions reflect? 1. Assessment 2. Diagnosis 3. Planning 4. Implementation
question
3. Intervention (I)
answer
Which category of the subjective, objective, assessment, plan, implementation, and evaluation (SOAPIE) format documents the step of implementation in the nursing process? 1. Subjective data (S) 2. Assessment (A) 3. Intervention (I) 4. Evaluation (E)
question
1. Concept mapping
answer
What is defined as a diagrammatic teaching and learning strategy that visualizes interrelationships between medical diagnoses and nursing diagnoses? 1. Concept mapping 2. Case management 3. Critical pathways of care (CPCs) 4. Focus charting
question
4. Assist the client in performing personal hygiene and grooming.
answer
A client with schizophrenia is diagnosed with a self-care deficit. Which activity should the nurse include in the treatment plan for the client? 1. Engage the client in physical activity. 2. Encourage verbalization of fears. 3. Provide adequate quantities of food and fluids. 4. Assist the client in performing personal hygiene and grooming.
question
2. Any recent change in weight
answer
Which information does the nurse find under the gastrointestinal section in the mental history form? 1. Chest pain 2. Any recent change in weight 3. Lifestyle factors 4. Phlebitis
question
1. From verbal reports of the client, family or other sources
answer
How is information from a client obtained for the subjective data when working within the subjective, objective, assessment, plan, implementation, and evaluation (SOAPIE) format? 1. From verbal reports of the client, family or other sources 2. From interpretation of the subjective and objective data by the nurse 3. From direct observation or examination by the nurse 4. From the nursing actions that were actually carried out
question
1. The client develops trust in the assigned staff member.
answer
While caring for a client with schizophrenia, the registered nurse assigns the same staff members to interact with the client. Which outcome does the registered nurse anticipate as a response to this intervention? 1. The client develops trust in the assigned staff member. 2. The client discusses the content of hallucinations with the staff member. 3. The client attends groups willingly without being accompanied by the staff member. 4. The client maintains personal hygiene at an acceptable level.
question
3. Appraisal of the client responses to determine effectiveness of nursing interventions
answer
What information is recorded in the problem (P) category of APIE (assessment, problem, intervention, evaluation) charting method? 1. Subjective and objective data of the client 2. Name of nursing diagnosis which is addressed from the written problem list 3. Appraisal of the client responses to determine effectiveness of nursing interventions 4. Nursing actions performed, which are directed at problem resolution
question
4. Naming objects
answer
Which area of mental function does the nurse evaluate during the brief mental status examination? 1. Thought content 2. Judgment 3. Mood 4. Naming objects
question
1. Using distraction to bring the client back to reality
answer
A client with schizophrenia is diagnosed with disturbed sensory perception. Which nursing action will be effective for this client? 1. Using distraction to bring the client back to reality 2. Avoiding whispering to others in the client's presence 3. Offering positive reinforcement for independent accomplishments 4. Serving food family style to the client
question
3. It reduces redundancy of information.
answer
What is the advantage of the use of electronic health records (EHRs) in the hospital? 1. It increases charting time. 2. It accepts multiple data types, such as graphs, photographs, and drawings. 3. It reduces redundancy of information. 4. it requires consistent use of standardized terminology.
question
1. Spending time with the client 4. Attending the group activities along with the client at initial stages 5. Teaching effective communication techniques to the client
answer
A client with schizophrenia is found to have low self-esteem. Which interventions should the nurse implement while caring for the client? Select all that apply. 1. Spending time with the client 2. Observing signs of hallucinations 3. Assigning the same staff as much as possible 4. Attending the group activities along with the client at initial stages 5. Teaching effective communication techniques to the client
question
1. Standard 5A 5. Standard 5F
answer
The registered nurse is conducting psychotherapy for a client with mental illness and is coordinating with other primary health-care providers for effective care. Which standards of clinical nursing practice is the nurse following in this scenario? Select all that apply. 1. Standard 5A 2. Standard 5B 3. Standard 5D 4. Standard 5E 5. Standard 5F
question
1. Diagnosis 2. Outcome identification
answer
The nurse is interpreting the subjective and objective data categories of a client who is newly admitted to a psychiatric unit. Which steps of the nursing process include this recording according to the SOAPIE format? Select all that apply. 1. Diagnosis 2. Outcome identification 3. Implementation 4. Assessment 5. Evaluation
question
2. Pertinent physical assessments
answer
The nurse is assessing the respiratory rate, musculoskeletal status, and side effects of medications used by the client in a psychiatric unit. Which section of the mental history form includes these assessments? 1. Reality orientation 2. Pertinent physical assessments 3. Drug history and assessment 4. Psychosomatic manifestations
question
2. P (Problem)
answer
Which category of APIE (assessment, problem, intervention, evaluation) charting reflects the diagnosis step of the nursing process? 1. A (Assessment) 2. P (Problem) 3. I (Intervention) 4. E (Evaluation)
question
4. Lightheadedness after exercising
answer
A client complains to the nurse, "I feel lightheaded after exercising." The nurse finds that the client has an unsteady gait, pale skin, and bruises on the right arm. What is the subjective data in the given scenario? 1. Bruises on the right arm 2. Presence of pale skin 3. Presence of unsteady gait 4. Lightheadedness after exercising
question
2. Maintaining a safe environment in the client's premises
answer
The nurse is following the nursing process for a schizophrenic client who has attempted suicide. Which nursing action is part of the implementation step of the nursing process? 1. Collecting the health data of the client including previous attempts of suicide 2. Maintaining a safe environment in the client's premises 3. Determining if nursing interventions have been appropriate to achieve desired results 4. Analyzing the health data of the client to produce desired results
question
2. E (Evaluation)
answer
Which step of the subjective, objective, assessment, plan, implementation, and evaluation (SOAPIE) format involves a reassessment of the situation to determine the results of actions implemented? 1. P (Plan) 2. E (Evaluation) 3. A (Assessment) 4. I (Intervention)
question
3. Assessment
answer
Which step of the nursing process involves recording the subjective and objective data of a client, according to the APIE (assessment, problem, intervention, evaluation) charting method? 1. Evaluation 2. Diagnosis 3. Assessment 4. Implementation
question
3. Implementation
answer
The nurse uses prescriptive authority, referrals, and treatments in accordance with state and federal laws and regulations. Which standard is the nurse practicing through this intervention? 1. Planning 2. Evaluation 3. Implementation 4. Outcomes identification
question
3. Social withdrawal
answer
While caring for a client with schizophrenia, the nurse suspects low self-esteem in the client. Which symptom in the client supports the nurse's suspicion? 1. Suspiciousness 2. Verbalizing about hearing voices 3. Social withdrawal 4. Unkempt appearance
question
1. Consultation
answer
What interventions does the standard 5G of psychiatric-mental health clinical nursing practice include? 1. Consultation 2. Psychotherapy 3. Milieu therapy 4. Prescriptive authority and treatment
question
1. The client has low self-esteem.
answer
The nurse encourages the client to verbalize his or her fears. What could be the client's condition? 1. The client has low self-esteem. 2. The client has a self-care deficit. 3. The client has disturbed thought processes. 4. The client has a disturbed sensory perception.
question
1. Paranoid delusions
answer
Which problem does the client with schizophrenia, who has an inability to trust others, exhibit? 1. Paranoid delusions 2. Social withdrawal 3. Auditory hallucinations 4. Developmental regression
question
3. Assessment, 5. Diagnosis, 1. Outcomes, 2. Planning, 4. Implementation, 6. Evaluation
answer
Arrange the steps of the nursing process in order according to the American Nurses Association (ANA). 1. Outcomes identification 2. Planning 3. Assessment 4. Implementation 5. Diagnosis 6. Evaluation
question
4. Intervention
answer
A client who sustained an accident is admitted into the health-care setting with minor injuries. The nurse monitors the client's skin and cleanses and dresses the wounds. Which step of the subjective, objective, assessment, plan, implementation, and evaluation (SOAPIE) format is the nurse following in this situation? 1. Planning 2. Evaluation 3. Assessment 4. Intervention
question
1. Spending time with the client 4. Attending the group activities along with the client at initial stages 5. Teaching effective communication techniques to the client
answer
A client with schizophrenia is found to have low self-esteem. Which interventions should the nurse implement while caring for the client? Select all that apply. 1. Spending time with the client 2. Observing signs of hallucinations 3. Assigning the same staff as much as possible 4. Attending the group activities along with the client at initial stages 5. Teaching effective communication techniques to the client
question
2. Analyzing the assessment data of the client
answer
Which intervention made by the registered nurse indicates that the nurse is following Standard 2 of the American Nurses Association (ANA) Standards of Practice effectively? 1. Collecting comprehensive health data of the client 2. Analyzing the assessment data of the client 3. Identifying the expected outcomes for a plan individualized to the client 4. Developing a plan to attain expected outcomes
question
3. Low self-esteem
answer
Which condition does the nursing team identify in the client with schizophrenia who is refusing to interact with the staff members in the hospital? 1. Disturbed sensory perception 2. Disturbed thought processes 3. Low self-esteem 4. Self-care deficit
question
1. Data (D) 2. Action (A) 4. Response (R)
answer
What are the categories that are included under the focus charting documentation method? Select all that apply. 1. Data (D) 2. Action (A) 3. Problem (P) 4. Response (R) 5. Intervention (I)
question
4. Intervention
answer
A client who sustained an accident is admitted into the health-care setting with minor injuries. The nurse monitors the client's skin and cleanses and dresses the wounds. Which step of the subjective, objective, assessment, plan, implementation, and evaluation (SOAPIE) format is the nurse following in this situation? 1. Planning 2. Evaluation 3. Assessment 4. Intervention
question
1. Distracting the client by changing the topic
answer
Which nursing action may help the nurse to manage hallucinations in a client with schizophrenia? 1. Distracting the client by changing the topic 2. Spending time with the client 3. Avoiding whispering to others in the client's presence 4. Assigning the same staff member to interact with the client
question
2. Standard 2
answer
Which standard of psychiatric-mental health clinical nursing practice provides the basis for selection of nursing interventions to achieve effective outcomes? 1. Standard 1 2. Standard 2 3. Standard 3 4. Standard 4
question
1. "What year is it?" 3. "What does this mean: 'No use crying over spilled milk'?" 4. "Name the months of the year in reverse, starting with December."
answer
While conducting the brief mental status evaluation in a client, the nurse evaluates various areas of mental function such as orientation to time, ability to concentrate, and abstract thinking by questioning the client. Which questions posed by the nurse will enable the nurse to evaluate these areas of mental function? Select all that apply. 1. "What year is it?" 2. "Where are you now?" 3. "What does this mean: 'No use crying over spilled milk'?" 4. "Name the months of the year in reverse, starting with December." 5. "Repeat these words now: bell, book, and candle."
