Chapter 11 My Nursing Test Banks

 

Kneisl, Contemporary Psychiatric-Mental Health Nursing, 3/e Test Bank
Chapter 11

Question 1

Type: MCSA

Which of the following best describes the information the nurse will use to construct a nursing care plan?

1. A mental status examination

2. An intake assessment and reason for admission

3. A psychiatric history and mental status examination

4. A detailed psychiatric history

Correct Answer: 3

Rationale 1: The psychiatric examination consists of the psychiatric history and mental status examination. The intake assessment and reason for admission are part of the psychiatric history, which includes the clients current condition, previous diagnosis, interventions, treatments, and a family history.

Rationale 2: The psychiatric examination consists of the psychiatric history and mental status examination. The intake assessment and reason for admission are part of the psychiatric history, which includes the clients current condition, previous diagnosis, interventions, treatments, and a family history.

Rationale 3: The psychiatric examination consists of the psychiatric history and mental status examination. The intake assessment and reason for admission are part of the psychiatric history, which includes the clients current condition, previous diagnosis, interventions, treatments, and a family history.

Rationale 4: The psychiatric examination consists of the psychiatric history and mental status examination. The intake assessment and reason for admission are part of the psychiatric history, which includes the clients current condition, previous diagnosis, interventions, treatments, and a family history.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: Perform an ongoing psychiatricmental health assessment of clients in your care.

Question 2

Type: MCSA

A nursing student is working to develop assessment skills. The student knows that nurses utilize principles of assessment:

1. Upon admission.

2. Throughout hospitalization.

3. At the point of entry to care.

4. Prior to discharge.

Correct Answer: 2

Rationale 1: Assessment is essential to the delivery of nursing care and is included at all phases of a clients hospitalization, beginning at the point of entry to care through discharge.

Rationale 2: Assessment is essential to the delivery of nursing care and is included at all phases of a clients hospitalization, beginning at the point of entry to care through discharge.

Rationale 3: Assessment is essential to the delivery of nursing care and is included at all phases of a clients hospitalization, beginning at the point of entry to care through discharge.

Rationale 4: Assessment is essential to the delivery of nursing care and is included at all phases of a clients hospitalization, beginning at the point of entry to care through discharge.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Determine how and when to apply assessment principles in professional practice.

Question 3

Type: MCMA

A nurse who is admitting a client to the inpatient unit conducts a comprehensive assessment. How does the nurse use the data gathered from the assessment?

Standard Text: Select all that apply.

1. To support nursing diagnoses

2. To determine the length of stay

3. To exclude data from secondary sources

4. To plan appropriate interventions

5. To make sound clinical judgments

Correct Answer: 1,4,5

Rationale 1: To support nursing diagnoses. Data obtained from the comprehensive assessment is used as support or evidence for the nursing diagnoses.

Rationale 2: To determine the length of stay. The length of stay may be estimated at the time of admission, but the determining factor is the clients progression in response to care.

Rationale 3: To exclude data from secondary sources. Data are obtained from both primary (client) and secondary (other) sources.

Rationale 4: To plan appropriate interventions. Assessment data are used in planning appropriate interventions related to the clients need(s).

Rationale 5: To make sound clinical judgments. Information obtained from the comprehensive assessment is used to make clinical decisions related to the clients need(s).

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: Determine how and when to apply assessment principles in professional practice.

Question 4

Type: MCSA

As part of the comprehensive admission assessment, the nurse talks with family and friends who may contribute additional data to a clients psychiatric history. When reviewing the data obtained from these sources, the nurse keeps in mind which of the following perspectives of the data? The information provided:

1. Will vary according to the sources relationship to the client.

2. Comes from each individuals perspective.

3. Is considered false.

4. Is considered accurate.

Correct Answer: 2

Rationale 1: Family and friends have their own perspectives through which they filter events. The sources of the information to be included in the psychiatric history and the sources relationship to the client should always be clearly indicated. Information given by these collateral sources should be reviewed and understood in terms of that relationship.

Rationale 2: Family and friends have their own perspectives through which they filter events. The sources of the information to be included in the psychiatric history and the sources relationship to the client should always be clearly indicated. Information given by these collateral sources should be reviewed and understood in terms of that relationship.

Rationale 3: Family and friends have their own perspectives through which they filter events. The sources of the information to be included in the psychiatric history and the sources relationship to the client should always be clearly indicated. Information given by these collateral sources should be reviewed and understood in terms of that relationship.

Rationale 4: Family and friends have their own perspectives through which they filter events. The sources of the information to be included in the psychiatric history and the sources relationship to the client should always be clearly indicated. Information given by these collateral sources should be reviewed and understood in terms of that relationship.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Elicit a psychiatric history from a client and the clients family.

Question 5

Type: MCSA

The nurse reviews the data family and friends provided in the comprehensive assessment of a clients situation. The nurse knows to treat the data as:

1. Invalid until confirmed with the client.

2. Subjective data.

3. Primary data.

4. Peripheral to the assessment.

Correct Answer: 2

Rationale 1: Information provided by family and friends is subjective, secondary data. Information from family and friends is not peripheral, but is treated as important data to be contributed to the whole assessment while recognizing that it does not provide a total picture of the client. Secondary data does not need to be confirmed with the client.

Rationale 2: Information provided by family and friends is subjective, secondary data. Information from family and friends is not peripheral, but is treated as important data to be contributed to the whole assessment while recognizing that it does not provide a total picture of the client. Secondary data does not need to be confirmed with the client.

Rationale 3: Information provided by family and friends is subjective, secondary data. Information from family and friends is not peripheral, but is treated as important data to be contributed to the whole assessment while recognizing that it does not provide a total picture of the client. Secondary data does not need to be confirmed with the client.

Rationale 4: Information provided by family and friends is subjective, secondary data. Information from family and friends is not peripheral, but is treated as important data to be contributed to the whole assessment while recognizing that it does not provide a total picture of the client. Secondary data does not need to be confirmed with the client.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Elicit a psychiatric history from a client and the clients family.

Question 6

Type: MCSA

The nurse is talking with the family of a mentally ill client who lives with them. The client is being admitted to the inpatient psychiatric unit. What is the priority information to gather from the family?

1. Whether the client had a flu shot recently

2. The number of medications prescribed for the client

3. How the clients symptoms are expressed at home

4. The type of soap the client prefers to use

Correct Answer: 3

Rationale 1: The most important information to be obtained from the family at the time of admission is how the symptoms of the clients illness are being expressed at home. This would be closely aligned to the chief complaint and provides a baseline for monitoring. The other information may be needed, but it is not the most important at the time of admission.

Rationale 2: The most important information to be obtained from the family at the time of admission is how the symptoms of the clients illness are being expressed at home. This would be closely aligned to the chief complaint and provides a baseline for monitoring. The other information may be needed, but it is not the most important at the time of admission.

Rationale 3: The most important information to be obtained from the family at the time of admission is how the symptoms of the clients illness are being expressed at home. This would be closely aligned to the chief complaint and provides a baseline for monitoring. The other information may be needed, but it is not the most important at the time of admission.

Rationale 4: The most important information to be obtained from the family at the time of admission is how the symptoms of the clients illness are being expressed at home. This would be closely aligned to the chief complaint and provides a baseline for monitoring. The other information may be needed, but it is not the most important at the time of admission.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Elicit a psychiatric history from a client and the clients family.

Question 7

Type: MCMA

The psychiatric examination includes a psychiatric history and a mental status assessment. When conducting the mental status assessment, the nurse:

Standard Text: Select all that apply.

1. Includes observations.

2. Limits the assessment to verbal responses.

3. Provides the client with a form to complete.

4. May or may not follow a strict sequence.

5. Uses a group format.

Correct Answer: 1,4

Rationale 1: Includes observations. Several components of the assessment require observational skills of the nurse.

Rationale 2: Limits the assessment to verbal responses. Observations of the clients nonverbal communication and other behaviors made by the nurse are included in the assessment.

Rationale 3: Provides the client with a form to complete. The nurse conducts the mental status assessment; the client is not given a form to complete.

Rationale 4: May or may not follow a strict sequence. The nurse is not required to follow a strict sequence or format.

Rationale 5: Uses a group format. The client is not assessed during group sessions, but the client is assessed during a one-to-one interaction.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Conduct a mental status examination on a client.

Question 8

Type: MCSA

A client makes the following statement during a mental status assessment: I cant use the phones; the CIA has bugged all the wires. Which of the following categories will the nurse use to document the clients response?

1. Orientation

2. Content of thought

3. Emotional state

4. General behavior

Correct Answer: 2

Rationale 1: Content of thought includes special preoccupations and experiences, including delusions. General behavior describes the clients physical characteristics. Emotional state refers to the persons pervasive or dominant mood. Orientation includes time, place, person, and self or purpose.

Rationale 2: Content of thought includes special preoccupations and experiences, including delusions. General behavior describes the clients physical characteristics. Emotional state refers to the persons pervasive or dominant mood. Orientation includes time, place, person, and self or purpose.

Rationale 3: Content of thought includes special preoccupations and experiences, including delusions. General behavior describes the clients physical characteristics. Emotional state refers to the persons pervasive or dominant mood. Orientation includes time, place, person, and self or purpose.

Rationale 4: Content of thought includes special preoccupations and experiences, including delusions. General behavior describes the clients physical characteristics. Emotional state refers to the persons pervasive or dominant mood. Orientation includes time, place, person, and self or purpose.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Conduct a mental status examination on a client.

Question 9

Type: MCSA

During a mental status assessment, the examiner asks the client to repeat these words: motorcar, teacup, and lilies. Five minutes later the client is asked to repeat the words again. The purpose of this exercise is to test the clients:

1. Insight.

2. Retention and recall.

3. Recall of recent past experiences.

4. Abstract thinking.

Correct Answer: 2

Rationale 1: Retention and recall is used to test immediate impressions. Recall of recent past experiences relates to the events leading to the present seeking of treatment. Abstract thinking relates to the clients ability to interpret simple fables of proverbs. Insight provides information about the clients ability to recognize the significance of the present situation.

Rationale 2: Retention and recall is used to test immediate impressions. Recall of recent past experiences relates to the events leading to the present seeking of treatment. Abstract thinking relates to the clients ability to interpret simple fables of proverbs. Insight provides information about the clients ability to recognize the significance of the present situation.

Rationale 3: Retention and recall is used to test immediate impressions. Recall of recent past experiences relates to the events leading to the present seeking of treatment. Abstract thinking relates to the clients ability to interpret simple fables of proverbs. Insight provides information about the clients ability to recognize the significance of the present situation.

Rationale 4: Retention and recall is used to test immediate impressions. Recall of recent past experiences relates to the events leading to the present seeking of treatment. Abstract thinking relates to the clients ability to interpret simple fables of proverbs. Insight provides information about the clients ability to recognize the significance of the present situation.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Conduct a mental status examination on a client.

Question 10

Type: MCSA

An anxious client is to complete the Minnesota Multiphasic Personality Inventory-2 as part of the psychological testing. The client is worried about not having enough time to prepare for the test. To decrease anxiety, the nurse reviews the purpose of the test and explains that the client will:

1. Just need to complete a series of sentences.

2. Interpret ink blots.

3. Only have to copy geometric designs.

4. Be answering true or false questions.

Correct Answer: 4

Rationale 1: The MMPI-2 contains true or false questions. The Rorschach test involves the interpretation of ink blots. The Mini-Mental State Exam measures the ability to copy geometric designs. The Sentence Completion Test requires the completion of a series of sentences.

Rationale 2: The MMPI-2 contains true or false questions. The Rorschach test involves the interpretation of ink blots. The Mini-Mental State Exam measures the ability to copy geometric designs. The Sentence Completion Test requires the completion of a series of sentences.

Rationale 3: The MMPI-2 contains true or false questions. The Rorschach test involves the interpretation of ink blots. The Mini-Mental State Exam measures the ability to copy geometric designs. The Sentence Completion Test requires the completion of a series of sentences.

Rationale 4: The MMPI-2 contains true or false questions. The Rorschach test involves the interpretation of ink blots. The Mini-Mental State Exam measures the ability to copy geometric designs. The Sentence Completion Test requires the completion of a series of sentences.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Describe the essential components of physiological assessment, neurologic assessment, psychological testing, and psychosocial assessment.

Question 11

Type: MCSA

A family member reports that his mother has started hiding valuables around the house, then cant remember where she put them. He asks the nurse to explain what is happening. Which of the following assessment tools might the nurse utilize to screen the mother for signs of cognitive dysfunction?

1. Benton Visual Retention Test

2. Thematic Apperception Test

3. Ravens Progressive Matrices Test

4. Sentence Completion Test

Correct Answer: 1

Rationale 1: The Benton Visual Retention Test is an example of a neuropsychological assessment instrument that can yield valuable data on aspects of a persons cognitive functioning. It is sometimes used as a quick screening device to see if the test taker may be manifesting signs of cognitive dysfunction. The Sentence Completion Test asks clients to complete an extensive series of incomplete sentences with the first thoughts that come to mind. The sentences are designed to elicit responses concerning fantasies, fears, daydreams, and aspirations, among other things, and are not used to screen for cognitive dysfunction. The Thematic Apperception Test is used to reveal very important information about the clients emotional and interpersonal tendencies and not as a screening tool for signs of cognitive dysfunction. Ravens Progressive Matrices Test is designed to provide data on intellectual ability in a relatively culturally unbiased manner and is not used to screen for cognitive dysfunction.

Rationale 2: The Benton Visual Retention Test is an example of a neuropsychological assessment instrument that can yield valuable data on aspects of a persons cognitive functioning. It is sometimes used as a quick screening device to see if the test taker may be manifesting signs of cognitive dysfunction. The Sentence Completion Test asks clients to complete an extensive series of incomplete sentences with the first thoughts that come to mind. The sentences are designed to elicit responses concerning fantasies, fears, daydreams, and aspirations, among other things, and are not used to screen for cognitive dysfunction. The Thematic Apperception Test is used to reveal very important information about the clients emotional and interpersonal tendencies and not as a screening tool for signs of cognitive dysfunction. Ravens Progressive Matrices Test is designed to provide data on intellectual ability in a relatively culturally unbiased manner and is not used to screen for cognitive dysfunction.

Rationale 3: The Benton Visual Retention Test is an example of a neuropsychological assessment instrument that can yield valuable data on aspects of a persons cognitive functioning. It is sometimes used as a quick screening device to see if the test taker may be manifesting signs of cognitive dysfunction. The Sentence Completion Test asks clients to complete an extensive series of incomplete sentences with the first thoughts that come to mind. The sentences are designed to elicit responses concerning fantasies, fears, daydreams, and aspirations, among other things, and are not used to screen for cognitive dysfunction. The Thematic Apperception Test is used to reveal very important information about the clients emotional and interpersonal tendencies and not as a screening tool for signs of cognitive dysfunction. Ravens Progressive Matrices Test is designed to provide data on intellectual ability in a relatively culturally unbiased manner and is not used to screen for cognitive dysfunction.

Rationale 4: The Benton Visual Retention Test is an example of a neuropsychological assessment instrument that can yield valuable data on aspects of a persons cognitive functioning. It is sometimes used as a quick screening device to see if the test taker may be manifesting signs of cognitive dysfunction. The Sentence Completion Test asks clients to complete an extensive series of incomplete sentences with the first thoughts that come to mind. The sentences are designed to elicit responses concerning fantasies, fears, daydreams, and aspirations, among other things, and are not used to screen for cognitive dysfunction. The Thematic Apperception Test is used to reveal very important information about the clients emotional and interpersonal tendencies and not as a screening tool for signs of cognitive dysfunction. Ravens Progressive Matrices Test is designed to provide data on intellectual ability in a relatively culturally unbiased manner and is not used to screen for cognitive dysfunction.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Describe the essential components of physiological assessment, neurologic assessment, psychological testing, and psychosocial assessment.

Question 12

Type: MCSA

A depressed client asks why a physical exam is necessary before being admitted for outpatient treatment. The nurse explains to the client that a physical exam will:

1. Provide information about medications the client will need.

2. Make sure the client gets all necessary treatment.

3. Complete the admission process.

4. Ensure the client has not ingested any caustic material or inhaled noxious vapors.

Correct Answer: 2

Rationale 1: The clients symptoms may be due to a biological or neurological problem causing depressive symptoms. The value of careful assessment of general health issues and screening for biologic disorders cannot be overemphasized; in some community settings, psychiatric-mental health nurses are the only mental health care providers prepared to undertake such an assessment and interpret the results. The exams scope is not limited to exposure to dangerous chemicals, nor is it performed solely to comply with institutional policy. Its findings will guide all aspects of the clients care, not just medication therapy.

Rationale 2: The clients symptoms may be due to a biological or neurological problem causing depressive symptoms. The value of careful assessment of general health issues and screening for biologic disorders cannot be overemphasized; in some community settings, psychiatricmental health nurses are the only mental health care providers prepared to undertake such an assessment and interpret the results. The exams scope is not limited to exposure to dangerous chemicals, nor is it performed solely to comply with institutional policy. Its findings will guide all aspects of the clients care, not just medication therapy.

Rationale 3: The clients symptoms may be due to a biological or neurological problem causing depressive symptoms. The value of careful assessment of general health issues and screening for biologic disorders cannot be overemphasized; in some community settings, psychiatric-mental health nurses are the only mental health care providers prepared to undertake such an assessment and interpret the results. The exams scope is not limited to exposure to dangerous chemicals, nor is it performed solely to comply with institutional policy. Its findings will guide all aspects of the clients care, not just medication therapy.

Rationale 4: The clients symptoms may be due to a biological or neurological problem causing depressive symptoms. The value of careful assessment of general health issues and screening for biologic disorders cannot be overemphasized; in some community settings, psychiatric-mental health nurses are the only mental health care providers prepared to undertake such an assessment and interpret the results. The exams scope is not limited to exposure to dangerous chemicals, nor is it performed solely to comply with institutional policy. Its findings will guide all aspects of the clients care, not just medication therapy.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Describe the essential components of physiological assessment, neurologic assessment, psychological testing, and psychosocial assessment.

Question 13

Type: MCSA

The nurse in the community mental health clinic assesses a client and determines the presence of an Axis II diagnosis. What conclusions can the nurse draw?

1. The client is in need of further evaluation.

2. The client has a personality disorder.

3. The client will need a special diet.

4. The client is a candidate for the least restrictive environment.

Correct Answer: 2

Rationale 1: Axis II contains the personality disorders usually diagnosed in adults, and developmental disorders including mental retardation, diagnosed in children and adolescents. Axis II is also used to report maladaptive personality traits. Information about diet and the level of care needed are written in the admission orders, not the multiaxial diagnosis.

Rationale 2: Axis II contains the personality disorders usually diagnosed in adults, and developmental disorders including mental retardation, diagnosed in children and adolescents. Axis II is also used to report maladaptive personality traits. Information about diet and the level of care needed are written in the admission orders, not the multiaxial diagnosis.

Rationale 3: Axis II contains the personality disorders usually diagnosed in adults, and developmental disorders including mental retardation, diagnosed in children and adolescents. Axis II is also used to report maladaptive personality traits. Information about diet and the level of care needed are written in the admission orders, not the multiaxial diagnosis.

Rationale 4: Axis II contains the personality disorders usually diagnosed in adults, and developmental disorders including mental retardation, diagnosed in children and adolescents. Axis II is also used to report maladaptive personality traits. Information about diet and the level of care needed are written in the admission orders, not the multiaxial diagnosis.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: Explain the importance of each of the five axes of the DSM multiaxial system to the overall assessment of clients and their families.

Question 14

Type: MCSA

A female client disclosed to the nurse that she is in an abusive situation. This information will be used to contribute to:

1. Axis IV.

2. Axis III.

3. Nothing, since this is confidential information and should not be shared.

4. Axis I.

Correct Answer: 1

Rationale 1: Axis IV is used to identify psychosocial problems that may affect the diagnosis and treatment of mental disorders. Clinicians use Axis III too.

Rationale 2: Axis IV is used to identify psychosocial problems that may affect the diagnosis and treatment of mental disorders. Clinicians use Axis III too.

Rationale 3: Axis IV is used to identify psychosocial problems that may affect the diagnosis and treatment of mental disorders. Clinicians use Axis III too.

Rationale 4: Axis IV is used to identify psychosocial problems that may affect the diagnosis and treatment of mental disorders. Clinicians use Axis III too.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Explain the importance of each of the five axes of the DSM multiaxial system to the overall assessment of clients and their families.

Question 15

Type: MCSA

The nurse on the inpatient unit is reviewing the record of a client admitted the previous day, and notes the client has an Axis I diagnosis. What inferences can the nurse make about the client?

1. The client has a clinical psychiatric disorder.

2. The client is in need of immediate medical attention.

3. The client has a chronic condition.

4. The client lacks a support system.

Correct Answer: 1

Rationale 1: Axis I provides information regarding major mental disorders, as well as developmental and learning disorders. Axis I does not provide information about support systems, chronic conditions, or indicate if the client is in need of immediate medical attention.

Rationale 2: Axis I provides information regarding major mental disorders, as well as developmental and learning disorders. Axis I does not provide information about support systems, chronic conditions, or indicate if the client is in need of immediate medical attention.

Rationale 3: Axis I provides information regarding major mental disorders, as well as developmental and learning disorders. Axis I does not provide information about support systems, chronic conditions, or indicate if the client is in need of immediate medical attention.

Rationale 4: Axis I provides information regarding major mental disorders, as well as developmental and learning disorders. Axis I does not provide information about support systems, chronic conditions, or indicate if the client is in need of immediate medical attention.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Explain the importance of each of the five axes of the DSM multiaxial system to the overall assessment of clients and their families.

Question 16

Type: MCMA

How might the nurse make use of the information contained in a clients multiaxial diagnosis?

Standard Text: Select all that apply.

1. To address physiological problems

2. To plan client-centered interventions

3. To communicate client needs

4. To assess client strengths

5. To identify nursing diagnoses

Correct Answer: 1,2,3,4,5

Rationale 1: The diagnosis and information contained in Axis I-IV can be utilized at all phases of the nursing process in developing and delivering client-centered nursing care.

Rationale 2: The diagnosis and information contained in Axis IIV can be utilized at all phases of the nursing process in developing and delivering client-centered nursing care.

Rationale 3: The diagnosis and information contained in Axis IIV can be utilized at all phases of the nursing process in developing and delivering client-centered nursing care.

Rationale 4: The diagnosis and information contained in Axis IIV can be utilized at all phases of the nursing process in developing and delivering client-centered nursing care.

Rationale 5: The diagnosis and information contained in Axis IIV can be utilized at all phases of the nursing process in developing and delivering client-centered nursing care.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: Explain the importance of each of the five axes of the DSM multiaxial system to the overall assessment of clients and their families.

Question 17

Type: MCSA

A client is admitted with the following diagnosis:

Axis I: 300.01 Panic disorder without agoraphobia

Axis II: 301.83 Borderline personality disorder

Axis III: No diagnosis

Axis IV: Unemployment

What conclusions can the nurse make relative to the clients Axis III information?

1. This client has problems with environment, but they are not related to mental disorder.

2. The clients environment has not been evaluated.

3. The clients health status has not been evaluated.

4. The client has no diagnosed physiological health problems relevant to mental disorder at the time of admission.

Correct Answer: 4

Rationale 1: Clinicians use Axis III to record physical disorders and medical conditions that must be taken into account in planning treatment at the time of admission. Axis IV is used to identify problems or issues of a psychosocial and environmental nature.

Rationale 2: Clinicians use Axis III to record physical disorders and medical conditions that must be taken into account in planning treatment at the time of admission. Axis IV is used to identify problems or issues of a psychosocial and environmental nature.

Rationale 3: Clinicians use Axis III to record physical disorders and medical conditions that must be taken into account in planning treatment at the time of admission. Axis IV is used to identify problems or issues of a psychosocial and environmental nature.

Rationale 4: Clinicians use Axis III to record physical disorders and medical conditions that must be taken into account in planning treatment at the time of admission. Axis IV is used to identify problems or issues of a psychosocial and environmental nature.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Explain the importance of each of the five axes of the DSM multiaxial system to the overall assessment of clients and their families.

Question 18

Type: MCSA

The school nurse, who must be familiar with mental health issues, will find child clinical disorders classified under:

1. Axis II.

2. Axis I.

3. Axis X.

4. Axis VII.

Correct Answer: 2

Rationale 1: Axis I includes all of the Adult and Child Clinical Disorders. Axis II contains the personality disorders, usually diagnosed in adults, and developmental disorders including mental retardation, diagnosed in children and adolescents. There is no Axis VII or X in the multiaxial system.

Rationale 2: Axis I includes all of the Adult and Child Clinical Disorders. Axis II contains the personality disorders, usually diagnosed in adults, and developmental disorders including mental retardation, diagnosed in children and adolescents. There is no Axis VII or X in the multiaxial system.

Rationale 3: Axis I includes all of the Adult and Child Clinical Disorders. Axis II contains the personality disorders, usually diagnosed in adults, and developmental disorders including mental retardation, diagnosed in children and adolescents. There is no Axis VII or X in the multiaxial system.

Rationale 4: Axis I includes all of the Adult and Child Clinical Disorders. Axis II contains the personality disorders, usually diagnosed in adults, and developmental disorders including mental retardation, diagnosed in children and adolescents. There is no Axis VII or X in the multiaxial system.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Explain the importance of each of the five axes of the DSM multiaxial system to the overall assessment of clients and their families.

Question 19

Type: MCSA

After interviewing a client for admission, the nurse gives the client a score of 50 on the Global Assessment of Functioning Scale (GAF). The nurse selected this score based on the clients level of functioning:

1. Since being given a psychiatric diagnosis.

2. Within the past week.

3. Since beginning the psychotropic medication.

4. Within the past year.

Correct Answer: 2

Rationale 1: The GAF Scale rates the clients lowest level of functioning within the previous seven days. The GAF Scale does not include impairment due to physical or environmental limitations.

Rationale 2: The GAF Scale rates the clients lowest level of functioning within the previous seven days. The GAF Scale does not include impairment due to physical or environmental limitations.

Rationale 3: The GAF Scale rates the clients lowest level of functioning within the previous seven days. The GAF Scale does not include impairment due to physical or environmental limitations.

Rationale 4: The GAF Scale rates the clients lowest level of functioning within the previous seven days. The GAF Scale does not include impairment due to physical or environmental limitations.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Incorporate the result of the GAF scale in a nursing care plan for a client with mental disorder.

Question 20

Type: MCSA

Select the priority nursing diagnosis for a client with a Global Assessment of Functioning (GAF) score of 10.

1. Risk for Impaired Social Interaction

2. Risk for Injury

3. Knowledge Deficit

4. Risk for Communication Deficit

Correct Answer: 2

Rationale 1: The client with a GAF of 10 manifests persistent danger of severely hurting self or others. In this case, the nurse wants to prevent the occurrence of an injury; therefore, the risk for injury supersedes the risk for impaired social interaction, risk for communication deficit, and knowledge deficit.

Rationale 2: The client with a GAF of 10 manifests persistent danger of severely hurting self or others. In this case, the nurse wants to prevent the occurrence of an injury; therefore, the risk for injury supersedes the risk for impaired social interaction, risk for communication deficit, and knowledge deficit.

Rationale 3: The client with a GAF of 10 manifests persistent danger of severely hurting self or others. In this case, the nurse wants to prevent the occurrence of an injury; therefore, the risk for injury supersedes the risk for impaired social interaction, risk for communication deficit, and knowledge deficit.

Rationale 4: The client with a GAF of 10 manifests persistent danger of severely hurting self or others. In this case, the nurse wants to prevent the occurrence of an injury; therefore, the risk for injury supersedes the risk for impaired social interaction, risk for communication deficit, and knowledge deficit.

Global Rationale:

Cognitive Level: Evaluating

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: Incorporate the result of the GAF scale in a nursing care plan for a client with mental disorder.

Question 21

Type: MCSA

The psychiatric home health nurse is evaluating whether a clients level of functioning has improved since starting the prescribed psychotropic medication. What evidence does the nurse look for?

1. There is no change in the GAF score.

2. There is a significant decrease (by 10 or more points) in the clients GAF score.

3. The client no longer qualifies for a GAF score.

4. There is an increase in the clients GAF score.

Correct Answer: 4

Rationale 1: The range of the Global Assessment of Functioning (GAF) score is 0100 with 0 indicating there is inadequate information and 100 indicating the client has superior functioning in a wide range of activities, lifes problems never seem to get out of hand, the client is sought out by others because of his or her many positive qualities, and the client is having no symptoms. When evaluating the GAF score, generally an increase over the score at admission indicates there is some improvement in the clients level of functioning.

Rationale 2: The range of the Global Assessment of Functioning (GAF) score is 0100 with 0 indicating there is inadequate information and 100 indicating the client has superior functioning in a wide range of activities, lifes problems never seem to get out of hand, the client is sought out by others because of his or her many positive qualities, and the client is having no symptoms. When evaluating the GAF score, generally an increase over the score at admission indicates there is some improvement in the clients level of functioning.

Rationale 3: The range of the Global Assessment of Functioning (GAF) score is 0100 with 0 indicating there is inadequate information and 100 indicating the client has superior functioning in a wide range of activities, lifes problems never seem to get out of hand, the client is sought out by others because of his or her many positive qualities, and the client is having no symptoms. When evaluating the GAF score, generally an increase over the score at admission indicates there is some improvement in the clients level of functioning.

Rationale 4: The range of the Global Assessment of Functioning (GAF) score is 0100 with 0 indicating there is inadequate information and 100 indicating the client has superior functioning in a wide range of activities, lifes problems never seem to get out of hand, the client is sought out by others because of his or her many positive qualities, and the client is having no symptoms. When evaluating the GAF score, generally an increase over the score at admission indicates there is some improvement in the clients level of functioning.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: Incorporate the result of the GAF scale in a nursing care plan for a client with mental disorder.

Kneisl, Contemporary Psychiatric-Mental Health Nursing, 3/e Test Bank

Copyright 2012 by Pearson Education, Inc.

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