Question 1

A newly admitted patient is severely depressed,lost 20 pounds over the past month,and expresses hopelessness for the future.Select the priority nursing diagnosis.

Accepted Answer

A)   Imbalanced nutrition: less than body requirements
B)   Chronic low self-esteem
C)   Risk for suicide
D)   Powerlessness C

Question 2

Which nursing documentation best meets the requirement for problem-oriented charting?

Accepted Answer

A)   "Pacing and muttering to self.Sensory perceptual alteration related to internal auditory stimulation.Given fluphenazine 2.5 mg PO at 0900 and went to room to lie down.Calmer by 0930.Returned to lounge to watch TV."
B)   "Agitated behavior.Patient muttering to self as though answering an unseen person.Given haloperidol 2 mg PO and went to room to lie down.Patient calmer within 30 minutes.Returned to lounge to watch TV."
C)   "S: States 'I feel like I'm ready to blow up.' O: Pacing hall,mumbling to self.A: Auditory hallucinations.P: Offer haloperidol 2 mg PO.I: Haloperidol 2 mg PO given at 0900.E: Returned to lounge at 0930 and quietly watched TV."
D)   "Pacing hall and muttering to self as though answering an unseen person.Haloperidol 2 mg PO administered at 0900,with calming effect in 30 minutes.Stated 'I'm no longer bothered by the voices.'" C

Question 3

Complete this nursing diagnosis: ___________ related to shyness and poorly developed social skills as evidenced by watching television alone at home every evening.

Accepted Answer

A)   Ineffective individual coping
B)   Deficient knowledge
C)   Powerlessness
D)   Social isolation D

Question 4

Select the best outcome for a patient with this nursing diagnosis: Impaired social interaction related to sociocultural dissonance as evidenced by stating,"Although I'd like to,I don't join in because I don't speak the language very well." Within 1 week,the patient will:

Accepted Answer

A)   demonstrate improved social skills.
B)   express a desire to interact with others.
C)   become more independent in decision making.
D)   select and participate in one group activity per day.

Question 5

A nurse assessing a new patient asks,"What is meant by the old saying,'You can't judge a book by looking at the cover'?" Which aspect of cognition is the nurse assessing?

Accepted Answer

A)   Memory
B)   Orientation
C)   Attention
D)   Abstraction

Question 6

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

Accepted Answer

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

Question 7

As a nurse assesses an elderly patient,answers seem vague or unrelated to the questions.The patient also leans forward and frowns,listening intently to the nurse.An appropriate question for the nurse to ask would be:

Accepted Answer

A)   "Are you having difficulty hearing when I speak?"
B)   "I notice you frowning.Are you feeling annoyed with me?"
C)   "How can I make this assessment interview easier for you?"
D)   "You're having trouble focusing on what I'm saying.What is distracting you?"

Question 8

A patient tells the nurse,"I feel very restless,and my muscles are stiff." Correctly sequence these actions,according to nursing process.
A) Administer medication to relieve the symptoms.
B) Confer with the health care provider about the findings.
C) Determine the measure of relief the patient experienced.
D) Collect additional information about the patient's complaints.
E) Decide the patient is experiencing side effects of antipsychotic medication.

Accepted Answer

The answer of A patient tells the nurse,"I feel very...

Question 9

An adolescent asks the nurse,"Why should I tell you anything? You'll just tell my parents whatever you find out." Select the nurse's best reply.

Accepted Answer

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

Question 10

A patient's nursing diagnosis is sleep-pattern disturbance.The desired outcome is: Patient will sleep for a minimum of 5 hours nightly by October 31.On November 1,review of sleep data for 6 days shows the patient slept an average of 4 hours nightly and took 2-hour afternoon naps daily.Which evaluation should be documented?

Accepted Answer

A)   Consistently demonstrated
B)   Often demonstrated
C)   Sometimes demonstrated
D)   Never demonstrated

Question 11

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

Accepted Answer

A)   Implement the nursing plan of care.
B)   Complete the spiritual assessment.
C)   Determine the goals and outcome criteria.
D)   Design interventions to include in the plan of care.

Question 12

A severely depressed patient lost 20 pounds over the past month,has chronic low self-esteem,and the intent and a plan for suicide.The patient has taken an antidepressant medication for 1 week.The nurse adds this outcome to the plan of care: Patient will refrain from gestures and attempts to harm self.Which nursing intervention is most directly related to this outcome?

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 13

When a new patient is hospitalized,a nurse takes the patient on a tour,explains rules of the unit,and explains the daily schedule.The nurse has fulfilled which aspect of care coordination?

Accepted Answer

A)   Counseling
B)   Health teaching
C)   Milieu management
D)   Integrative therapy

Question 14

A nurse assessing a patient with a substance use disorder decides to use a standardized rating scale.Which scale(s)are appropriate? More than one answer is correct.

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 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:

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

Nursing behaviors associated with the implementation phase of the nursing process are concerned with:

Accepted Answer

A)   carrying out interventions and coordinating care.
B)   comparing patient responses and expected outcomes.
C)   gathering accurate and sufficient patient-centered data.
D)   participating in mutual identification of patient outcomes.

Question 17

After a nurse assesses a new patient with a psychiatric disorder,nursing diagnoses are formulated.Information conveyed by the nursing diagnoses includes: (More than one answer is correct. )

Accepted Answer

A)   medical judgments about the disorder.
B)   goals and outcomes for the plan of care.
C)   unmet patient needs present at the moment.
D)   supporting data that validate the diagnoses.
E)   probable causes that will be targets for nursing interventions.

Question 18

A patient states: "I'm not worth anything.I have negative thoughts about myself.I want to go to sleep and never wake up." Which nursing intervention has the highest priority?

Accepted Answer

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

Question 19

During an initial assessment,a patient becomes anxious and evasive when the nurse asks,"Have you ever heard voices when no one else was around?" The patient asks,"Why do you need to know that?" Select the nurse's best response.

Accepted Answer

A)   "Please be honest about these experiences," and repeat the question.
B)   "Sometimes questions seem very personal,but we have our reasons for asking."
C)   "What purpose do you think we might have in asking whether you hear voices?"
D)   "I can see this subject makes you uncomfortable.We can discuss it another time."

Question 20

A patient is very suspicious and states,"The FBI has me under surveillance." Which strategies should the nurse to use when gathering initial assessment data about this patient? More than one answer is correct.

Accepted Answer

A)   Say to the patient,"Tell me about the problem as you see it."
B)   Tell the patient medication will help this type of thinking.
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."

Exam 8: The Nursing Process and Standards of Care for Psychiatric Mental Health Nursing