Question 1

Which data-gathering technique is employed during the assessment phase of the nursing process?

Accepted Answer

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 
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

Question 2

The following North American Nursing Diagnosis Association (NANDA)nursing diagnostic stem was developed for a client on an inpatient unit: Risk for injury.What assessment data most likely led to the development of this problem statement?

Accepted Answer

A)  The client is receiving electroconvulsive therapy (ECT) and is diagnosed with Parkinsonism. 
B)  The client has a history of four suicide attempts in adolescence. 
C)  The client expresses hopelessness and helplessness and isolates self. 
D)  The client has disorganized thought processes and delusional thinking. 
A)  The client is receiving electroconvulsive therapy (ECT) and is diagnosed with Parkinsonism. 
B)  The client has a history of four suicide attempts in adolescence. 
C)  The client expresses hopelessness and helplessness and isolates self. 
D)  The client has disorganized thought processes and delusional thinking.

Question 3

The nurse interviewed a client who was uncooperative,answered questions with minimal responses,and rarely made eye contact.Which is the most complete documentation of baseline data obtained during the interview?

Accepted Answer

A)  "Appears uncooperative. Exhibits characteristics of depression." 
B)  "Maintains poor eye contact throughout interview process. Unable to answer interview questions due to depression." 
C)  "States 'I don't need to be here' when discussing admission status. Maintains minimal eye contact and offers little data related to triggers for admission." 
D)  "Unwilling to respond openly during interview." 
A)  "Appears uncooperative. Exhibits characteristics of depression." 
B)  "Maintains poor eye contact throughout interview process. Unable to answer interview questions due to depression." 
C)  "States 'I don't need to be here' when discussing admission status. Maintains minimal eye contact and offers little data related to triggers for admission." 
D)  "Unwilling to respond openly during interview."

Question 4

An adolescent client has problems expressing anger appropriately.Which nursing statement would encourage the client to set realistic goals?

Accepted Answer

A)  "What do you think needs to change about how you express anger?" 
B)  "How did you feel after attending the anger management session?" 
C)  "On a scale of 1 to 10, please rate your current level of anger." 
D)  "What bothers you about the actions of others when you get angry?" 
A)  "What do you think needs to change about how you express anger?" 
B)  "How did you feel after attending the anger management session?" 
C)  "On a scale of 1 to 10, please rate your current level of anger." 
D)  "What bothers you about the actions of others when you get angry?"

Question 5

During an intake interview,which question would assist the nurse in gathering data about the client's judgment?

Accepted Answer

A)  "What brought you to the hospital? Do you know what day and season it is now?" 
B)  "On a scale of 1 to 10, how would you rate your stress level?" 
C)  "What does the phrase 'a rolling stone gathers no moss' mean to you?" 
D)  "If you found a stamped, addressed envelope in the street, what would you do?" 
A)  "What brought you to the hospital? Do you know what day and season it is now?" 
B)  "On a scale of 1 to 10, how would you rate your stress level?" 
C)  "What does the phrase 'a rolling stone gathers no moss' mean to you?" 
D)  "If you found a stamped, addressed envelope in the street, what would you do?"

Question 6

A client who has slept 6 hours the previous night reports this to the assigned psychiatric nurse.What should be the initial nursing action to address this situation?

Accepted Answer

A)  Provide warm milk and a backrub. 
B)  Give a sleep medication. 
C)  Hold a relaxation group before bedtime. 
D)  Review the client's normal sleep pattern. 
A)  Provide warm milk and a backrub. 
B)  Give a sleep medication. 
C)  Hold a relaxation group before bedtime. 
D)  Review the client's normal sleep pattern.

Question 7

A client is assigned the nursing diagnosis of impaired social interaction R/T sociocultural differences AEB client stating,"Although I'd like to,I don't join in because I don't speak the language so good." Which correctly written outcome addresses this client's problem?

Accepted Answer

A)  The client will collaborate with nursing staff to set specific goals by day 3. 
B)  The client will participate in one group activity of choice by day 2. 
C)  The client will express a desire to interact with others. 
D)  The client will become increasingly independent by discharge. 
A)  The client will collaborate with nursing staff to set specific goals by day 3. 
B)  The client will participate in one group activity of choice by day 2. 
C)  The client will express a desire to interact with others. 
D)  The client will become increasingly independent by discharge.

Question 8

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?

Accepted Answer

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. 
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.

Question 9

Which tool would be appropriate for a nurse to use when assessing mental acuity prior to and immediately following electroconvulsive therapy (ECT)?

Accepted Answer

A)  CIWA scale 
B)  GGT 
C)  MMSE 
D)  CAPS scale 
A)  CIWA scale 
B)  GGT 
C)  MMSE 
D)  CAPS scale

Question 10

A client diagnosed with schizophrenia is exhibiting nonverbal behaviors indicating that the client is hearing things that others do not.Which nursing diagnosis accurately reflects this client's problem?

Accepted Answer

A)  Altered thought processes 
B)  Altered sensory perception 
C)  Anxiety 
D)  Chronic confusion 
A)  Altered thought processes 
B)  Altered sensory perception 
C)  Anxiety 
D)  Chronic confusion

Question 11

Which nursing diagnosis should a nurse identify as being correctly formulated?

Accepted Answer

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 
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

Question 12

After a comprehensive assessment,correctly written nursing diagnoses developed for psychiatric clients may include which of the following components? Select all that apply.

Accepted Answer

A)  Medical judgments related to the psychiatric disorder 
B)  Unmet client needs present at the moment 
C)  Supporting data that validate the diagnosis 
D)  Outcomes that will be targets for nursing interventions 
E)  Statements of client problems of a functional nature 
A)  Medical judgments related to the psychiatric disorder 
B)  Unmet client needs present at the moment 
C)  Supporting data that validate the diagnosis 
D)  Outcomes that will be targets for nursing interventions 
E)  Statements of client problems of a functional nature

Question 13

What is being assessed when a nurse asks a client to identify name,date,residential address,and situation?

Accepted Answer

A)  Mood 
B)  Perception 
C)  Orientation 
D)  Affect 
A)  Mood 
B)  Perception 
C)  Orientation 
D)  Affect

Exam 9: The Nursing Process in Psychiatric/Mental Health Nursing

Which data-gathering technique is employed during the assessment phase of the nursing process?

The following North American Nursing Diagnosis Association (NANDA)nursing diagnostic stem was developed for a client on an inpatient unit: Risk for injury.What assessment data most likely led to the development of this problem statement?

The nurse interviewed a client who was uncooperative,answered questions with minimal responses,and rarely made eye contact.Which is the most complete documentation of baseline data obtained during the interview?

An adolescent client has problems expressing anger appropriately.Which nursing statement would encourage the client to set realistic goals?

During an intake interview,which question would assist the nurse in gathering data about the client's judgment?

A client who has slept 6 hours the previous night reports this to the assigned psychiatric nurse.What should be the initial nursing action to address this situation?

A client is assigned the nursing diagnosis of impaired social interaction R/T sociocultural differences AEB client stating,"Although I'd like to,I don't join in because I don't speak the language so good." Which correctly written outcome addresses this client's problem?

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?

Which tool would be appropriate for a nurse to use when assessing mental acuity prior to and immediately following electroconvulsive therapy (ECT)?

A client diagnosed with schizophrenia is exhibiting nonverbal behaviors indicating that the client is hearing things that others do not.Which nursing diagnosis accurately reflects this client's problem?

Which nursing diagnosis should a nurse identify as being correctly formulated?

After a comprehensive assessment,correctly written nursing diagnoses developed for psychiatric clients may include which of the following components? Select all that apply.

What is being assessed when a nurse asks a client to identify name,date,residential address,and situation?

The Concept of Stress Adaptation

Mental Health/Mental Illness: Historical and Theoretical Concepts

Theoretical Models of Personality Development

Concepts of Psychobiology

Ethical and Legal Issues

Cultural and Spiritual Concepts Relevant to Psychiatric/Mental Health Nursing

Relationship Development

Therapeutic Communication

Therapeutic Groups

Intervention With Families

Milieu Therapy The Therapeutic Community

Crisis Intervention

Assertiveness Training

Promoting Self Esteem

Anger/Aggression Management

The Suicidal Client

Behavior Therapy

Cognitive Therapy

Electroconvulsive Therapy

The Recovery Model

Neurocognitive Disorders

Substance-Related and Addictive Disorders

Schizophrenia Spectrum and Other Psychotic Disorders

Depressive Disorders

Bipolar and Related Disorders

Anxiety, Obsessive-Compulsive, and Related Disorders

Trauma and Stressor Related Disorders

Somatic Symptom and Dissociative Disorders

Issues Related to Human Sexuality and Gender Dysphoria

Eating Disorders

Personality Disorders

Children and Adolescents

The Aging Individual

Survivors of Abuse or Neglect

Community Mental Health Nursing

The Bereaved Individual

Military Families

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