Chapter 10- The Psychiatric Nursing Process My Nursing Test Banks

 

1.

Which of the following questions would be most helpful in beginning an initial assessment interview for a patient who has just been admitted to a psychiatric inpatient unit?

A)

Have you had any previous psychiatric admissions?

B)

What brings you into the hospital today?

C)

Have you had any thoughts about trying to harm yourself?

D)

How would you describe your relationship with your spouse?

2.

A patient is being admitted to the psychiatric unit. While explaining his reason for seeking admission, he describes how his 32-year-old son recently died of a heart attack. Which response by the nurse would enhance the effectiveness of this interview?

A)

How is your wife handling your sons death?

B)

Do you have any other living children that can help you cope with this loss?

C)

This must be a very difficult time for you.

D)

I know exactly how youre feeling; my 23-year-old son died unexpectedly last year.

3.

A patient was admitted to the hospital after a suicide attempt made after his daughter was killed in an automobile accident during which he had been driving and survived with only minor injuries. Even though the accident was unavoidable, he feels responsible. During the assessment interview, the patient begins to describe the last conversation he had with his daughter before he lost control of the automobile. As he speaks about his daughter, his voice trembles, and a silent tear rolls down his face. He makes a visible attempt to straighten up and smiles superficially at the nurse, stating, Ill get over this. I just need to keep a stiff upper lip. I think all I need to do is stay overnight. Ill be as good as new by tomorrow. Which response by the nurse would be most appropriate?

A)

Tell me about your daughter. How would you describe the relationship you had with her?

B)

Im sure you are right; a good nights rest should make a big difference.

C)

As good as new?

D)

You made a serious attempt on your life; you will not be ready go home by tomorrow.

4.

After assessing a patient, the nurse noted the following: he was tearful, he tried to kill himself before coming into the hospital, he had no immediate plan for another suicide attempt, he was unable to concentrate, and he reported having trouble sleeping and having little or no appetite. The nurse also noted that the patients appearance was unkempt, that he spoke in a low monotone, and that he was unable to establish and maintain eye contact. Based on this information, which nursing diagnoses would be the most appropriate?

A)

Ineffective Role Performance

B)

Risk for Infection

C)

Risk for Suicide

D)

Risk for Self-Mutilation

5.

A staff nurse on a psychiatric unit knows that patients often have trouble sleeping because of their psychiatric conditions. Which of the following would reflect a psychiatric nursing intervention to appropriately address this problem?

A)

Limiting amounts of evening snacks and beverages

B)

Involving patients in a volleyball game immediately before bedtime

C)

Enforcing the rule that all patients be in bed with lights out by 10:30 PM

D)

Encouraging patients to take short naps in the afternoons

6.

The nurse is determining the success of a patients plan of care by evaluating outcome indicators. The nurse understands that these indicators are usually determined initially at which time?

A)

On the day of discharge

B)

During the assessment process

C)

At the initial interview

D)

With goal-setting process

7.

Based on assessment data, the nurse formulates the nursing diagnosis for a patient as sleep pattern disturbance. After teaching the patient how to relax before bedtime, the nurse determines that the teaching was effective by which outcome?

A)

Discusses feelings about not being able to fall asleep

B)

Reports feeling rested on awakening in the morning within 3 days

C)

Requests sleeping medication each night before bedtime

D)

Is able to sleep for short intervals throughout the night

8.

A patient was brought to the emergency department for an injury he received while working as a migrant worker. It soon becomes evident that the patient cannot speak English. A nurse on duty offers to find an interpreter so the patient can communicate with the medical staff. The nurses offer is an example of which type of nursing intervention?

A)

Milieu therapy

B)

Conflict resolution

C)

Cultural brokering

D)

Structured interaction

9.

A home health nurse is making a home visit to a psychiatric patient who was recently discharged from a mental health unit. During the visit, the nurse plans on clarifying with the patient when she will return for the next home visit. During which stage would the nurse discuss the next home visit with the patient?

A)

Closure stage

B)

Service implementation

C)

Greeting stage

D)

Focus establishment

10.

The nurse is reviewing the assessment data of a patient diagnosed with a mental illness. The patient is to be prescribed medication to treat the illness. The nurse would identify changes in which laboratory values as being the least significant?

A)

Hemoglobin

B)

Alanine aminotransferase (ALT)

C)

Blood urea nitrogen (BUN) level

D)

Serum creatinine

11.

A nurse is performing a biopsychosocial assessment of a patient with depression. Which of the following would the nurse assess as part of the psychological domain? Select all that apply.

A)

Abstract reasoning

B)

Medication use

C)

Mood

D)

Orientation

E)

Self-care

12.

During assessment, the nurse asks a patient to explain what the following means: A penny saved is a penny earned. The nurse is assessing which of the following?

A)

Affect

B)

Attention

C)

Concentration

D)

Abstract reasoning

13.

The nurse is reviewing the drawing that a patient completed as a self-portrait. The nurse observes that the drawing lacks arms and feet. The nurse interprets this as indicating which of the following? Select all that apply.

A)

Low self-esteem

B)

Powerlessness

C)

Insecurity

D)

Inadequacy

14.

A nurse identifies a nursing diagnosis of chronic low self-esteem. Which statement by a patient would support this nursing diagnosis?

A)

I feel so ugly.

B)

No one wants to date me.

C)

Im so fat, like a cow.

D)

I never do anything right.

15.

A nurse is assessing a patients spirituality. Which question would be most appropriate to ask?

A)

Have you ever tried to harm yourself?

B)

How important is your family to you?

C)

How do you define good and evil?

D)

What gives your life meaning?

16.

A nurse is assisting a patient in using simple relaxation techniques. Which of the following would the nurse do first?

A)

Have the patient assume a relaxed position.

B)

Advise the patient to let the sensations happen.

C)

Ensure a quiet, nondisrupting environment.

D)

Instruct the patient to take an initial slow, deep breath.

17.

A group of nursing students are reviewing information about counseling interventions. The students demonstrate a need for additional review when they identify counseling interventions as involving which of the following?

A)

Specific, time-limited intervention

B)

Focus on coping improvement

C)

Goal of regaining functional abilities

D)

Prevention of disability

18.

A patient is engaged in bibliotherapy and begins to express his feelings because he closely associates his experience with that provided by the reading material. The nurse interprets this as which of the following?

A)

Insight

B)

Catharsis

C)

Anxiety reduction

D)

Problem solving

19.

After teaching a group of nursing students about milieu therapy, the instructor determines that additional teaching is needed when the students identify which of the following as a key concept of milieu therapy?

A)

Structure interaction

B)

Open communication

C)

Validation

D)

De-escalation

20.

The nurse is assessing a patients immediate and short-term memory. Which of the following would be most appropriate?

A)

Questioning the patient about an event that has occurred within the past several months

B)

Giving the patient a simple scenario and having him identify what would be the best response

C)

Giving the patient three words and asking him to recite them now and then in 5 minutes

D)

Asking the patient to tell the nurse the date, time, and current location

Answer Key

1.

B

2.

C

3.

D

4.

C

5.

A

6.

B

7.

B

8.

C

9.

A

10.

A

11.

A, C, D

12.

D

13.

B, D

14.

D

15.

D

16.

C

17.

C

18.

B

19.

D

20.

C

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