Question 1

A patient begins a new program to assist with building social skills. In which part of the plan of care should a nurse record the item, "Encourage patient to attend one psychoeducational group daily"?

Accepted Answer

A)   Assessment
B)   Analysis
C)   Implementation
D)   Evaluation C

Question 2

A nurse asks a patient, "If you had a fever and vomiting for 3 days, what would you do?" Which aspect of the mental status examination is the nurse assessing?

Accepted Answer

A)   Behaviour
B)   Cognition
C)   Affect and mood
D)   Perceptual disturbances B

Question 3

A patient presents to the emergency department with mixed psychiatric symptoms. The admission nurse suspects the symptoms may be the result of a medical problem. Lab results show elevated BUN (blood urea nitrogen) and creatinine. What is the nurse's next best action?

Accepted Answer

A)   Report the findings to the health care provider.
B)   Assess the patient for a history of renal problems.
C)   Assess the patient's family history for cardiac problems.
D)   Arrange for the patient's hospitalization on the psychiatric unit. B

Question 4

The desired outcome for a patient experiencing insomnia is, "Patient will sleep for a minimum of 5 hours nightly within 7 days." At the end of 7 days, review of sleep data shows the patient sleeps an average of 4 hours nightly and takes a 2-hour afternoon nap. What is the nurse's next action?

Accepted Answer

A)   Continue the current plan without changes.
B)   Remove this nursing diagnosis from the plan of care.
C)   Write a new nursing diagnosis that better reflects the problem.
D)   Examine interventions for possible revision of the target date.

Question 5

What information is conveyed by nursing diagnoses?

Accepted Answer

A)   Medical judgements about the disorder
B)   Unmet patient needs currently present
C)   Goals and outcomes for the plan of care
D)   Supporting data that validate the diagnoses
E)   Probable causes that will be targets for nursing interventions

Question 6

A nurse documents, "Patient is mute despite repeated efforts to elicit speech. Makes no eye contact. Inattentive to staff. Gazes off to the side or looks upward rather than at speaker." Which nursing diagnosis should be considered?

Accepted Answer

A)   Defensive coping
B)   Decisional conflict
C)   Risk for other-directed violence
D)   Impaired verbal communication

Question 7

A patient diagnosed with major depression has lost 9 kilograms in one month, has chronic low self-esteem, and a plan for suicide. The patient has taken an antidepressant medication for 1 week. Which nursing intervention has the highest priority?

Accepted Answer

A)   Implement suicide precautions.
B)   Offer high-calorie snacks and fluids frequently.
C)   Assist the patient to identify three personal strengths.
D)   Observe patient for therapeutic effects of antidepressant medication.

Question 8

The desired outcome for a patient experiencing insomnia is, "Patient will sleep for a minimum of 5 hours nightly within 7 days." At the end of 7 days, review of sleep data shows the patient sleeps an average of 4 hours nightly and takes a 2-hour afternoon nap. The nurse will document the outcome as which of the following?

Accepted Answer

A)   Consistently met
B)   Often met
C)   Sometimes met
D)   Unmet

Question 9

A patient is very suspicious and states, "The FBI has me under surveillance." Which strategies should a nurse use when gathering initial assessment data about this patient?

Accepted Answer

A)   Tell the patient that medication will help this type of thinking.
B)   Ask the patient, "Tell me about the problem as you see it."
C)   Seek information about when the problem began.
D)   Tell the patient, "Your ideas are not realistic."
E)   Reassure the patient, "You are safe here."

Question 10

A nurse prepares to assess a new patient who moved to Canada from Central America three years ago. After introductions, what is the nurse's next comment?

Accepted Answer

A)   "How did you get to Canada?"
B)   "Would you like for a family member to help you talk with me?"
C)   "An interpreter is available. Would you like for me to make a request for these services?"
D)   "Are you comfortable conversing in English, or would you prefer to have a translator present?"

Question 11

What does the nurse assess when completing the final "S" of the HEADSSS Psychosocial Interview Technique?

Accepted Answer

A)   Suicide risk
B)   Savagery
C)   Sexuality
D)   Social support

Question 12

After formulating the nursing diagnoses for a new patient, what is a nurse's next action?

Accepted Answer

A)   Designing interventions to include in the plan of care
B)   Determining the goals and outcome criteria
C)   Implementing the nursing plan of care
D)   Completing the spiritual assessment

Question 13

A nurse assesses an older adult patient brought to the emergency department by a family member. The patient was wandering outside saying, "I can't find my way home." The patient is confused and unable to answer questions. Select the nurse's best action.

Accepted Answer

A)   Record the patient's answers to questions on the nursing assessment form.
B)   Ask an advanced-practice nurse to perform the assessment interview.
C)   Call for a mental health advocate to maintain the patient's rights.
D)   Obtain important information from the family member.

Question 14

An adolescent asks a nurse conducting an assessment interview, "Why should I tell you anything? You'll just tell my parents whatever you find out." Which response by the nurse is appropriate?

Accepted Answer

A)   "That isn't true. What you tell us is private and held in strict confidence. Your parents have no right to know."
B)   "Yes, your parents may find out what you say, but it is important that they know about your problems."
C)   "What you say about your feelings is private, but some things, like suicidal thinking, must be reported to the treatment team."
D)   "It sounds as though you are not really ready to work on your problems and make changes."

Question 15

Before assessing a new patient, a nurse is told by another health care worker, "I know that patient. No matter how hard we work, there isn't much improvement by the time of discharge." The nurse's responsibility is to do which of the following?

Accepted Answer

A)   Document the other worker's assessment of the patient
B)   Assess the patient based on data collected from all sources
C)   Validate the worker's impression by contacting the patient's significant other
D)   Discuss the worker's impression with the patient during the assessment interview

Question 16

A nurse wants to assess an adult patient's recent memory. Which question would best yield the desired information?

Accepted Answer

A)   "Where did you go to elementary school?"
B)   "What did you have for breakfast this morning?"
C)   "Can you name the current president of the United States?"
D)   "A few minutes ago, I told you my name. Can you remember it?"

Question 17

The nurse records this entry in a patient's progress notes: Patient escorted to unit by ER nurse at 2130. Patient's clothing was dirty. In interview room, patient sat with hands over face, sobbing softly. Did not acknowledge nurse or reply to questions. After several minutes, abruptly arose, ran to window, and pounded. Shouted repeatedly, "Let me out of here." Verbal intervention unsuccessful. Order for stat dose 2 mg haloperidol PO obtained; medication administered at 2150. By 2215, patient stopped shouting and returned to sit wordlessly in chair. Patient placed on one-to-one observation. How should this documentation be evaluated?

Accepted Answer

A)   Uses unapproved abbreviations
B)   Contains subjective material
C)   Too brief to be of value
D)   Excessively wordy
E)   Meets standards

Question 18

When a new patient is hospitalized, a nurse takes the patient on a tour, explains rules of the unit, and discusses the daily schedule. The nurse is engaged in which of the following?

Accepted Answer

A)   Counselling
B)   Health teaching
C)   Milieu management
D)   Psychobiological intervention

Question 19

A nurse performing an assessment interview for a patient with a substance use disorder decides to use a standardized rating scale. Which scales are appropriate?

Accepted Answer

A)   Addiction Severity Index (ASI) 
B)   Brief Drug Abuse Screen Test (B-DAST) 
C)   Abnormal Involuntary Movement Scale (AIMS) 
D)   Cognitive Capacity Screening Examination (CCS
E)  
E)   Recovery Attitude and Treatment Evaluator (RAAT
E)

Question 20

A patient states, "I'm not worth anything. I have negative thoughts about myself. I feel anxious and shaky all the time. Sometimes I feel so sad that I want to go to sleep and never wake up." Which nursing intervention should have the highest priority?

Accepted Answer

A)   Self-esteem-building activities
B)   Anxiety self-control measures
C)   Sleep enhancement activities
D)   Suicide precautions

Exam 6: The Nursing Process and Standards of Care for Psychiatric Mental Health Nursing