Chapter 6: Nursing Process in Mental Health My Nursing Test Banks

Chapter 6: Nursing Process in Mental Health

Multiple Choice

Identify the choice that best completes the statement or answers the question.

____ 1. After the admission of the patient, Nurse Toni will get specific information from the patient. This method of getting information is known as the:

A.

Termination phase when discharge plans are being made.

B.

Working phase, when the patient shows some progress.

C.

The patient interview.

D.

Working phase, when the patient brings it up.

____ 2. A systematic and individualized method of planning and providing care is best known as:

A.

Assessment.

B.

Nursing process.

C.

Diagnosis.

D.

Implementation.

____ 3. A patient is admitted to the Mental Illness and Chemical Abuse (MICA) unit for detox from the use of alcohol. During the interview, the patient states, My wife would rather see me dead. To which part of the nursing process does this belong?

A.

Planning

B.

Implementation

C.

Evaluation

D.

Assessment

____ 4. A patient is admitted into a mental health unit screaming and kicking. Although this patient is acting out, she also is verbalizing that her leg is hurting. What type of planning would benefit this patient the most?

A.

Short-term goal

B.

Long-term goal

C.

Intervention

D.

Evaluation

____ 5. You find a patient on the floor at shift change. She is awake and alert. She is confused now and was not confused prior to the being found on the floor. What is your first step in the nursing process in this situation?

A.

Leave the patient to get help.

B.

Gather more information by making observations about the patient.

C.

Call the patients MD from your cell phone.

D.

Help the patient get up and then document your findings in the chart.

____ 6. Short-term and long-term goals are which part of the nursing process?

A.

Assessment

B.

Nursing diagnosis

C.

Planning

D.

Implementation

E.

Evaluation

____ 7. In the principles of teaching, which abbreviation is used to describe the nursing process?

A.

ABES

B.

AAPE

C.

APIE

D.

ABLE

____ 8. NANDA is the acronym for:

A.

New American Nursing Diagnosis Association.

B.

National American Nursing Diagnosis Association.

C.

North American Nursing Diagnosis Analyzer.

D.

North American Nursing Diagnosis Association.

____ 9. In the Mental Health Status Examination, which of the following focuses on what the person is thinking?

A.

Speech and the ability to communicate

B.

Judgment

C.

Memory

D.

Thinking/content of thought

____ 10. The component of the Mental Health Status Examination that focuses on the way a person experiences reality is assessing the persons:

A.

Thinking/content of thought.

B.

Perception.

C.

Judgment.

D.

Mood and affect.

____ 11. The Mental Health Status Exam takes place in what step of the nursing process?

A.

Evaluation

B.

Nursing diagnosis

C.

Intervention

D.

Assessment

____ 12. In the planning phase of the nursing process, establishing short- and long-term goals is very important. Planning should:

A.

Include positive and negative outcomes.

B.

Be realistic and measureable.

C.

Be formal and informal.

D.

Focus on the best possible options even if unrealistic.

____ 13. Which is an accurate planning goal?

A.

The patient will lose 20 pounds when he agrees to follow the prescribed diet

B.

The patient will lose 20 pounds in 20 days

C.

The patient will lose 1 to 2 pounds a week until the goal of 20 pounds is reached.

D.

The patient will lose 2 pounds a week for 10 weeks.

Completion

Complete each statement.

14. The interaction of the nurse and patient that requires a nurse to obtain specific information from a patient is known as the _______________ ______________.

15. While on your way to another room, you notice a patient is having trouble using the call light. You stop and provide directions on how to use the call light. This is an example of what type of __________________ teaching.

16. The final step in the nursing process is ____________________.

17. The most important component of the nursing process that precedes the nursing intervention and is prepared by the registered nurse is the ____________ ___________.

18. The organization that developed the initial concept of nursing diagnosis is _______________.

19. The nursing diagnosis is the function of this member of the health care team: ___________ ____________.

20. Carrying out the specific steps to achieve a patients goals is called the _______________.

21. When the LPN/LVN sets a specific time to sit with the patient to go over diabetes education, this is considered ________________ teaching.

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

____ 22. Informal teaching takes place under the following conditions (select all that apply):

A.

Anytime

B.

Anywhere

C.

A preset curriculum

D.

Whenever the patient needs information

E.

You notice the patient looking at the dressing on their wound

F.

A scheduled class

____ 23. The LPN/LVN, assisting in the preparation of the care plan of the elderly patient with moderate cognitive impairment, should plan the goals to be (select all that apply):

A.

The entire responsibility of the nurse.

B.

Measurable.

C.

Realistic.

D.

Should include the patient in the process.

____ 24. The following are guidelines for the nurse-patient interview (select all that apply):

A.

Advise the patient

B.

Be aggressive

C.

Be sensitive

D.

Use empathy

E.

Use open-ended questions

____ 25. The following are components of the principles of teaching (select all that apply):

A.

Know the patient

B.

Lecture

C.

Demonstration

D.

Be flexible

E.

Plan to allow a few minutes after the class for questions

F.

Have a teaching plan

____ 26. The Mental Health Status Examination is an assessment of the patients mental status and current mental functioning. The following are components of the Mental Health Status Examination (select all that apply):

A.

Appearance and behavior.

B.

Level of awareness and orientation.

C.

Glasgow scale.

D.

Judgment.

E.

Mood and effect.

____ 27. The role of the LPN/LVN to the nursing process is (select all that apply):

A.

Assisting the registered nurse with the nursing diagnosis.

B.

Collecting data.

C.

Completing the initial assessment.

D.

Developing principles of teaching.

E.

Planning care and prioritizing goals.

____ 28. The nursing process includes: (select all that apply)

A.

Assessment.

B.

Planning.

C.

Diagnosis.

D.

Implementation.

E.

Case management.

F.

Evaluation.

Other

29. The nursing process is a systematic method of caring for a patient (place in the order they will occur):

____A. Evaluation.

____B. Planning.

____C. Assessment.

____D. Nursing diagnosis.

____E. Implementation.

Chapter 6: Nursing Process in Mental Health

Answer Section

MULTIPLE CHOICE

1. ANS: C

When the nurse and patient agree to work together, data is collected from the patient. The patient interview process begins as soon as the nurse walks in the room with the intention of obtaining the information.

PTS: 1

REF: Chapter 6: Nursing Process in Mental Health; The Intake Admission Interview; page 94

KEY: Integrated Processes: Communication and Documentation | Content Area: Mental Health: Therapeutic Communication | Cognitive Level: Comprehension | Client Need: Safe and Effective Care Environment: Coordinated Care

2. ANS: B

The nursing process is a tool used in nursing to assist in providing care in a systematic manner.

PTS: 1

REF: Chapter 6: Nursing Process in Mental Health; The Steps of the Nursing Process; page 89

KEY: Integrated Processes: Nursing Process: Planning | Content Area: Nursing Process | Cognitive Level: Knowledge | Client Need: Safe and Effective Care Environment: Continuity of Care

3. ANS: D

The patient is making a statement that would be included with subjective data as part of the assessment.

PTS: 1 REF: Chapter 6: Nursing Process in Mental Health; page 90

KEY: Integrated Processes: Nursing Process: Assessment | Content Area: Mental Health: Therapeutic Nursing Process | Cognitive Level: Synthesis | Client Need: Safe and Effective Care Environment: Management of Care: Continuity of Care

4. ANS: A

The plan should be to provide the patient with short-term care first. If the pain in her leg is reduced, the patient will possibly stop screaming. Planning needs to occur before intervention.

PTS: 1 REF: Chapter 6: Nursing Process in Mental Health; page 95-96

KEY: Integrated Processes: Nursing Process: Planning | Content Area: Mental Health: Nursing Process | Cognitive Level: Application | Client Need: Safe and Effective Care Environment: Coordinated Care

5. ANS: B

Being the first person on scene, you need to find out as much information as possible to report to the charge nurse as part of data collection. Never leave the patient alone until you are sure the patient is secure.

PTS: 1 REF: Chapter 6: Nursing Process in Mental Health; Data Collection; page 90

KEY: Integrated Processes: Nursing Process: Implementation | Content Area: Management of Care | Cognitive Level: Application | Client Need: Safe and Effective Care Environment: Coordinated Care

6. ANS: C

Short-term and long-term goals are part of planning in the nursing process.

PTS: 1 REF: Chapter 6: Nursing Process in Mental Health; Nursing Process; page 95-96

KEY: Integrated Processes: Nursing Process: Planning | Content Area: Mental Health: Therapeutic Nursing Process: | Cognitive Level: Comprehension | Client Need: Safe and Effective Care Environment: Coordinated Care

7. ANS: C

The very simple formats APIE for the nursing process may be easily transformed into a teaching format. APIE stands for Assessment, Plan, Intervention, Evaluation.

PTS: 1

REF: Chapter 6: Nursing Process in Mental Health; Principles of Teaching; page 90, 94-97, 100

KEY: Integrated Processes: Teaching/Learning: Nursing Process: Planning | Content Area: Management of Care | Cognitive Level: Comprehension | Client Need: Health Promotion and Maintenance: Data-Collection Techniques

8. ANS: D

The North American Nursing Diagnosis Association developed nursing diagnoses that define the patients problems after performing the patients assessment using a universal language. The nursing diagnosis can only be written by the registered nurse.

PTS: 1

REF: Chapter 6: Nursing Process in Mental Health; Nursing Diagnosis-Defining Patient Problems; page 95

KEY: Integrated Processes: Nursing Process: Assessment, Planning | Content Area: Management of Care | Cognitive Level: Comprehension | Client Need: Health Promotion and Maintenance: Data-Collection Techniques

9. ANS: D

Thinking/content of thought describes the content and process used in thinking. Alterations can include flight of ideas or obsessions.

PTS: 1

REF: Chapter 6: Nursing Process in Mental Health; Table 6-1, Mental Health Status Examination; page 92

KEY: Integrated Processes: Communication and Documentation | Content Area: Mental Health: Therapeutic Nursing Process: Management of Care | Cognitive Level: Comprehension | Client Need: Health Promotion and Maintenance: Data-Collection Techniques

10. ANS: B

Perception is the way a person experiences reality. This assessment also is based on the patients statement of his or her environment and behaviors associated with those statements.

PTS: 1

REF: Chapter 6: Nursing Process in Mental Health; Table 6-1, Mental Health Status Examination; page 93

KEY: Integrated Processes: Communication and Documentation | Content Area: Mental Health: Therapeutic Nursing Process | Cognitive Level: Comprehension | Client Need: Health Promotion and Maintenance: Data-Collection Techniques

11. ANS: D

The Mental Health Status Exam aids in the assessment process. The Mental Health Status checks eight different areas.

PTS: 1

REF: Chapter 6: Nursing Process in Mental Health; Assessing the Patients Mental Health; page 90

KEY: Integrated Processes: Nursing Process: Assessment | Content Area: Mental Health: Nursing Process: Assessment | Cognitive Level: Synthesis | Client Need: Health Promotion and Maintenance: Data-Collections Techniques

12. ANS: B

Goals need to be realistic, attainable, and measurable by establishing a realistic target date of achievement.

PTS: 1 REF: Chapter 6: Nursing Process in Mental Health; Planning Care; page 96

KEY: Integrated Processes: Nursing Process: Planning | Content Area: Mental Health: Therapeutic Nursing Process | Cognitive Level: Analysis | Client Need: Safe and Effective Care Environment: Management of Care: Establishing Priorities

13. ANS: C

In order to provide attainable goals, each goal should be measurable, realistic and individualizedaccording to the patients emotional and physical health. The goal should also be measurable, by establishing a realistic target date of achievement.

PTS: 1 REF: Chapter 6: Nursing Process in Mental Health; Planning Care; page 96

KEY: Integrated Processes: Nursing Process: Planning | Content Area: Mental Health: Therapeutic Nursing Process | Cognitive Level: Application | Client Need: Safe and Effective Care Environment: Management of Care: Establishing Priorities

COMPLETION

14. ANS:

patient interview

The patient interview is the primary method of data collecting used in health care.

PTS: 1

REF: Chapter 6: Nursing Process in Mental Health; Step 1: Assessing the patients mental health; page 94

KEY: Integrated Processes: Communication and Documentation | Content Area: Mental Health: Therapeutic Process | Cognitive Level: Knowledge | Client Need: Safe and Effective Care Environment: Coordinated Care:

15. ANS:

informal teaching

Informal teaching happens anytime, anywhere, whenever the patient needs information.

PTS: 1 REF: Chapter 6: Nursing Process in Mental Health; Patient Teaching; page 97

KEY: Integrated Processes: Teaching/Learning | Content Area: Management of Care | Cognitive Level: Application | Client Need: Health Promotion and Maintenance: Principles of Teaching/Learning

16. ANS:

evaluation

The LPN/LVN will note if the interventions performed were ineffective in attaining the patients goals.

PTS: 1

REF: Chapter 6: Nursing Process in Mental Health; Evaluating Interventions; page 100

KEY: Integrated Processes: Nursing Process: Evaluation | Content Area: Management of Care | Cognitive Level: Comprehension | Client Need: Safe and Effective Care Environment: Management of care: continuity of care

17. ANS:

nursing diagnosis

The nursing diagnosis defines the problem of the patient using standardized language.

PTS: 1

REF: Chapter 6: Nursing Process in Mental Health; Nursing Diagnosis-Defining Patient Problems; page 95

KEY: Integrated Processes: Nursing Process: Nursing Diagnosis | Content Area: Mental Health: Nursing Process in Mental Health | Cognitive Level: Knowledge | Client Need: Safe and Effective Care Environment: Coordinated Care

18. ANS:

NANDANorth American Nursing Diagnosis Association

NANDA developed the first list of standardized nursing diagnoses that are used worldwide by nurses to communicate about patients needs.

PTS: 1

REF: Chapter 6: Nursing Process in Mental Health; Nursing Diagnosis-Defining Patient Problems; page 95

KEY: Integrated Processes: Communication and Documentation/ Nursing Process: Planning | Content Area: Nursing Trends | Cognitive Level: Knowledge | Client Need: Safe and Effective Care Environment: Management of Care: Continuity of Care

19. ANS:

registered nurse

Processing the collected data from the assessment is a function of the registered nurse according to the ANA.

PTS: 1

REF: Chapter 6: Nursing Process in Mental Health; Nursing Diagnosis-Defining Patient Problems; page 95

KEY: Integrated Processes: Nursing Process: Planning | Content Area: Licensure | Cognitive Level: Knowledge | Client Need: Health Promotion and Maintenance: Data-Collection Techniques

20. ANS:

intervention or implementation

The implementation/intervention identifies the steps that the LPN/LVN will carry out to meet the patients goal. The nurse should be able to supply the reason for each intervention.

PTS: 1

REF: Chapter 6: Nursing Process in Mental Health; Step 4 Implementations/Interventions; page 96

KEY: Integrated Processes: Nursing Process: Planning/Implementation | Content Area: Nursing Licensure | Cognitive Level: Comprehension | Client Need: Safe and Effective Care Environment: Coordinated Care

21. ANS:

formal

Formal teaching is any situation in which a class is scheduled or a specific objective must be met such as management of blood sugars.

PTS: 1

REF: Chapter 6: Nursing Process in Mental Health; Step 4: Implementations/Interventions; page 97

KEY: Integrated Processes: Teaching/Learning | Content Area: Management of Care | Cognitive Level: Application | Client Need: Health Promotion and Maintenance: Principles of Teaching/Learning

MULTIPLE RESPONSE

22. ANS: A, B, D, E

Informal teaching can occur anytime or any place, especially when the patient asks for information or when the nurse notices the patient is in need of education.

PTS: 1

REF: Chapter 6: Nursing Process in Mental Health; Implementations/Interventions; page 97

KEY: Integrated Processes: Teaching/Learning | Content Area: Mental Health: Nursing Process: Implementation | Cognitive Level: Comprehension | Client Need: Health Promotion and Maintenance: Health Promotion/Disease Prevention

23. ANS: B, C, D

Goals and planning set by the nurse should be realistic and measureable for the patient. A goal date should be established during planning.

PTS: 1 REF: Chapter 6: Nursing Process in Mental Health; Step 3 Planning; page 95-96

KEY: Integrated Processes: Nursing Process: Planning | Content Area: Mental Health: Therapeutic Nursing Process | Cognitive Level: Application | Client Need: Health Promotion and Maintenance: Aging Process

24. ANS: C, D, E

The patient interview is the time to obtain information rather than give advice.

PTS: 1 REF: Chapter 6: Nursing Process in Mental Health; Patient Interview; page 95

KEY: Integrated Processes: Communication and Documentation | Content Area: Mental Health: Therapeutic Nursing Process | Cognitive Level: Application | Client Need: Health Promotion and Maintenance: Data-Collection Techniques

25. ANS: A, D, E, F

The principles of teaching allow the nurse to provide an appropriate type of education concerning the patient in the disease process. B and C are teaching methods.

PTS: 1 REF: Chapter 6: Nursing Process in Mental Health; Patient Teaching; page 98-99

KEY: Integrated Processes: Teaching/Learning | Content Area: Management of Care | Cognitive Level: Comprehension | Client Need: Health Promotion and Maintenance: Principles of Teaching/Learning

26. ANS: A, B, D

The mental health status examination includes the following: appearance, behavior, level of awareness, orientation, thought content, memory, speech, mood and affect, judgment, and perception.

PTS: 1

REF: Chapter 6: Nursing Process in Mental Health; Table 6.1, Mental Health Status Examination; page 91 and 93

KEY: Integrated Processes: Communication and Documentation | Content Area: Mental Health: Therapeutic Communication | Cognitive Level: Comprehension | Client Need: Health Promotion and Maintenance: Health Screening

27. ANS: A, B

The LPN/LVN can assist the registered nurse with the nursing diagnosis. The nursing diagnosis is the responsibility of the registered nurse. The LPN/LVN can collect data in order to implement care.

PTS: 1

REF: Chapter 6: Nursing Process in Mental Health; Step-by-Step Implementation of the Nursing Process; page 97

KEY: Integrated Processes: Nursing Process | Content Area: Nursing Licensure | Cognitive Level: Comprehension | Client Need: Safe and Effective Care Environment: Coordinated Care

28. ANS: A, B, C, D, F

The nursing process has these five components.

PTS: 1

REF: Chapter 6: Nursing Process in Mental Health; Step-by-Step Implementation of the Nursing Process; Figure 6-1 Steps in the nursing process; page 90

KEY: Integrated Processes: Nursing Process | Content Area: Management of Care | Cognitive Level: Comprehension | Client Need: Safe and Effective Care Environment: Coordinated Care

OTHER

29. ANS:

A: 5

B: 3

C: 1

D: 2

E: 4

The order of the nursing process is assessment, nursing diagnosis, planning, implementation, and outcome. The nursing process is a systematic approach in taking care of a patient.

PTS: 1

REF: Chapter 6: Nursing Process in Mental Health; Step-by-Step Implementation of the Nursing Process; Figure 6-1 Steps in the nursing process; page 90

KEY: Integrated Processes: Nursing Process | Content Area: Mental Health: Therapeutic Nursing Process | Cognitive Level: Application | Client Need: Health Promotion and Maintenance: Coordinated Care

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