MENTAL HEALTH 2 TESTBANK – UPDATED TESTBANK
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The Nursing Process in Psychiatric/Mental Health Nursing
1. Which data-gathering technique is employed during the assessment phase of the nursing process?
C. Asking the client to describe any thoughts of self-harm
The nurse should ask the client to describe any thoughts of self-harm during the assessment phase of
the nursing process. Assessment involves collecting and analyzing data about the client that may
include the following dimensions: physical, psychological, sociocultural, spiritual, cognitive,
developmental, economic, lifestyle, and functional abilities. The other three options are employed
during the evaluation phase of the nursing process.
2. Which statement is most accurate regarding the assessment of clients diagnosed with psychiatric
problems?
B. Assessment provides a holistic view of the client, including biopsychosocial aspects.
The assessment of clients diagnosed with psychiatric problems should provide a holistic view of the
client. A thorough assessment involves collecting and analyzing data from the client, significant
others, and health-care providers that may include the following dimensions: physical,
psychological, sociocultural, spiritual, cognitive, developmental, economic, lifestyle, and functional
abilities.
3. Which nursing diagnosis should a nurse identify as being correctly formulated?
B. Self-care deficit: hygiene R/T altered thought as AEB disheveled appearance
The nurse should determine that the correctly written diagnosis would be Self-care deficit: hygiene
R/T altered thought AEB disheveled appearance. The nursing diagnosis should describe the
unhealthy response (inference), the contributing factors, and the data that support the inference.
4. Which expected client outcome should a nurse identify as being correctly formulated?
D. Client will initiate interaction with one peer during free time within 2 days.
The statement “Client will initiate interaction with one peer during free time within 2 days” is an
example of a correctly formulated expected outcome. Outcomes should be measurable, realistic,
client-focused goals that include a time frame. Appropriate nursing interventions are guided by client
outcomes.
5. Which statement regarding nursing interventions should a nurse identify as accurate?
C. Nursing interventions occur independently but in concert with overall treatment team goals.
The nurse should understand that nursing interventions occur independently but in concert with
overall treatment goals. Nursing interventions should be developed and implemented in collaboration
with other health-care professionals involved in the client’s care.
6. Within the nurse’s scope of practice, which function is exclusive to the advance practice psychiatric
nurse?
B. Using psychotherapy to improve mental health status
,The advanced practice psychiatric nurse is authorized to use psychotherapy to improve mental health.
This includes individual, couples, group, and family psychotherapy. It is within the scope of practice of
a registered psychiatric mental health nurse generalist to provide education, case management, and
milieu therapy.
7. A nurse charts “Verbalizes understanding of the side effects of Prozac.” This is an example of
which category of focused charting?
,D. Response
“Verbalizes understanding of the side effects of Prozac” is an example of the response category of
focused charting. The response is a description of the client’s reaction to any part of medical or
nursing care.
8. The nurse should recognize which acronym as representing problem-oriented charting?
A. SOAPIE
The acronym SOAPIE represents problem-oriented charting, which reflects the subjective, objective,
assessment, plan, implementation, and evaluation format. This type of charting identifies nursing
diagnoses (client problems) on a written plan of care with appropriate nursing interventions
described for each.
9. Which tool would be appropriate for a nurse to use when assessing mental acuity prior to
and immediately following electroconvulsive therapy (ECT)?
C. MMSE
The MMSE, or mini mental status exam, would be the appropriate tool to use to assess the mental
acuity of a client prior to and immediately following ECT. The CIWA scale, or clinical institute
withdrawal assessment scale, would be used to assess withdrawal from substances such as alcohol.
The CAPS refers to the clinician-administered PTSD scale and would be used to assess signs and
symptoms of PTSD. The GGT test is used to assess gamma-glutamyl transferase levels, which may
be an indication of alcoholism.
10.What is being assessed when a nurse asks a client to identify name, date, residential address, and
situation?
C. Orientation
The nurse should ask the client to identify name, date, residential address, and situation to assess the
client’s orientation. Assessment of the client’s orientation to reality is part of a mental status
evaluation.
11.What is the purpose when a nurse gathers client information?
B. It enables the nurse to make sound clinical judgments and plan appropriate client care.
The purpose of gathering client information is to enable the nurse to make sound clinical nursing
judgments and plan appropriate care. The nurse should complete a thorough assessment of the
client, including information collected from the client, significant others, and health-care providers
(consistent with HIPAA laws and the client’s right to confidentiality).
12.A nurse on an inpatient psychiatric unit implements care by scheduling client activities,
interacting with clients, and maintaining a safe therapeutic environment. These actions reflect
which role of the nurse?
C. Milieu manager
The milieu manager implements care by scheduling client activities, interacting with clients, and
maintaining a safe therapeutic environment. Health teaching involves promoting health and a safe
environment. Case management is utilized to organize client care so that outcomes are achieved.
Psychotherapy involves conducting individual, couples, group, and family counseling.
, 13.The following outcome was developed for a client: “Client will list five personal strengths by the
end of day 1.” Which correctly written nursing diagnostic statement most likely generated the
development of this outcome?
A. Altered self-esteem R/T years of emotional abuse AEB self-deprecating statements
.
The Nursing Process in Psychiatric/Mental Health Nursing
1. Which data-gathering technique is employed during the assessment phase of the nursing process?
C. Asking the client to describe any thoughts of self-harm
The nurse should ask the client to describe any thoughts of self-harm during the assessment phase of
the nursing process. Assessment involves collecting and analyzing data about the client that may
include the following dimensions: physical, psychological, sociocultural, spiritual, cognitive,
developmental, economic, lifestyle, and functional abilities. The other three options are employed
during the evaluation phase of the nursing process.
2. Which statement is most accurate regarding the assessment of clients diagnosed with psychiatric
problems?
B. Assessment provides a holistic view of the client, including biopsychosocial aspects.
The assessment of clients diagnosed with psychiatric problems should provide a holistic view of the
client. A thorough assessment involves collecting and analyzing data from the client, significant
others, and health-care providers that may include the following dimensions: physical,
psychological, sociocultural, spiritual, cognitive, developmental, economic, lifestyle, and functional
abilities.
3. Which nursing diagnosis should a nurse identify as being correctly formulated?
B. Self-care deficit: hygiene R/T altered thought as AEB disheveled appearance
The nurse should determine that the correctly written diagnosis would be Self-care deficit: hygiene
R/T altered thought AEB disheveled appearance. The nursing diagnosis should describe the
unhealthy response (inference), the contributing factors, and the data that support the inference.
4. Which expected client outcome should a nurse identify as being correctly formulated?
D. Client will initiate interaction with one peer during free time within 2 days.
The statement “Client will initiate interaction with one peer during free time within 2 days” is an
example of a correctly formulated expected outcome. Outcomes should be measurable, realistic,
client-focused goals that include a time frame. Appropriate nursing interventions are guided by client
outcomes.
5. Which statement regarding nursing interventions should a nurse identify as accurate?
C. Nursing interventions occur independently but in concert with overall treatment team goals.
The nurse should understand that nursing interventions occur independently but in concert with
overall treatment goals. Nursing interventions should be developed and implemented in collaboration
with other health-care professionals involved in the client’s care.
6. Within the nurse’s scope of practice, which function is exclusive to the advance practice psychiatric
nurse?
B. Using psychotherapy to improve mental health status
,The advanced practice psychiatric nurse is authorized to use psychotherapy to improve mental health.
This includes individual, couples, group, and family psychotherapy. It is within the scope of practice of
a registered psychiatric mental health nurse generalist to provide education, case management, and
milieu therapy.
7. A nurse charts “Verbalizes understanding of the side effects of Prozac.” This is an example of
which category of focused charting?
,D. Response
“Verbalizes understanding of the side effects of Prozac” is an example of the response category of
focused charting. The response is a description of the client’s reaction to any part of medical or
nursing care.
8. The nurse should recognize which acronym as representing problem-oriented charting?
A. SOAPIE
The acronym SOAPIE represents problem-oriented charting, which reflects the subjective, objective,
assessment, plan, implementation, and evaluation format. This type of charting identifies nursing
diagnoses (client problems) on a written plan of care with appropriate nursing interventions
described for each.
9. Which tool would be appropriate for a nurse to use when assessing mental acuity prior to
and immediately following electroconvulsive therapy (ECT)?
C. MMSE
The MMSE, or mini mental status exam, would be the appropriate tool to use to assess the mental
acuity of a client prior to and immediately following ECT. The CIWA scale, or clinical institute
withdrawal assessment scale, would be used to assess withdrawal from substances such as alcohol.
The CAPS refers to the clinician-administered PTSD scale and would be used to assess signs and
symptoms of PTSD. The GGT test is used to assess gamma-glutamyl transferase levels, which may
be an indication of alcoholism.
10.What is being assessed when a nurse asks a client to identify name, date, residential address, and
situation?
C. Orientation
The nurse should ask the client to identify name, date, residential address, and situation to assess the
client’s orientation. Assessment of the client’s orientation to reality is part of a mental status
evaluation.
11.What is the purpose when a nurse gathers client information?
B. It enables the nurse to make sound clinical judgments and plan appropriate client care.
The purpose of gathering client information is to enable the nurse to make sound clinical nursing
judgments and plan appropriate care. The nurse should complete a thorough assessment of the
client, including information collected from the client, significant others, and health-care providers
(consistent with HIPAA laws and the client’s right to confidentiality).
12.A nurse on an inpatient psychiatric unit implements care by scheduling client activities,
interacting with clients, and maintaining a safe therapeutic environment. These actions reflect
which role of the nurse?
C. Milieu manager
The milieu manager implements care by scheduling client activities, interacting with clients, and
maintaining a safe therapeutic environment. Health teaching involves promoting health and a safe
environment. Case management is utilized to organize client care so that outcomes are achieved.
Psychotherapy involves conducting individual, couples, group, and family counseling.
, 13.The following outcome was developed for a client: “Client will list five personal strengths by the
end of day 1.” Which correctly written nursing diagnostic statement most likely generated the
development of this outcome?
A. Altered self-esteem R/T years of emotional abuse AEB self-deprecating statements
