NURS 260 EXAM 1 - 2204 THE NURSING PROCESS IN
PSYCHIATRIC/MENTAL HEALTH NURSING QUESTIONS AND
ANSWERS WITH COMPLETE SOLUTIONS
Which data gathering technique is employed during the assessment phase of the
nursing process?
A. Asking the client to rate mood after administering an antidepressant
B. Asking the client to verbalize understanding of previously explained unit rules
C. Asking the client to describe any thoughts of self-harm
D. Asking the client if the group on assertiveness skills was helpful
ANS: C
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.
Which statement is most accurate regarding the assessment of clients diagnosed
with psychiatric problems?
A. Medical history is of little significance and can be eliminated from the nursing
assessment.
,B. Assessment provides a holistic view of the client including biopsychosocial
aspects.
C. Comprehensive assessments can be performed only by advanced practice
nurses.
D. Psychosocial evaluations are gained by subjective reports rather than
objective observations.
ANS: B
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.
Which nursing diagnosis should a nurse identify as being correctly formulated?
A. Schizophrenia R/T biochemical alterations AEB altered thought
B. Self-care deficit: hygiene R/T altered thought as AEB disheveled appearance
C. Depressed mood R/T multiple life stressors
D. Developmental disability R/T early-onset schizophrenia AEB hallucinations
ANS: B
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 client's condition, facilitating the choice of interventions.
, Which expected client outcome should a nurse identify as being correctly
formulated?
A. Client will feel happier by discharge.
B. Client will demonstrate two relaxation techniques.
C. Client will verbalize triggers to anger by end of session.
D. Client will initiate interaction with one peer during free time within 2 days.
ANS: D
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.
Which statement regarding nursing interventions should a nurse identify as
accurate?
A. Nursing interventions are independent from the treatment team's goals.
B. Nursing interventions are solely directed by written physician orders.
C. Nursing interventions occur independently but in concert with overall
treatment team goals.
D. Nursing interventions are standardized by policies and procedures.
ANS: C
The nurse should understand that nursing interventions occur independently but in
concert with overall treatment goals. Nursing interventions should be developed and
PSYCHIATRIC/MENTAL HEALTH NURSING QUESTIONS AND
ANSWERS WITH COMPLETE SOLUTIONS
Which data gathering technique is employed during the assessment phase of the
nursing process?
A. Asking the client to rate mood after administering an antidepressant
B. Asking the client to verbalize understanding of previously explained unit rules
C. Asking the client to describe any thoughts of self-harm
D. Asking the client if the group on assertiveness skills was helpful
ANS: C
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.
Which statement is most accurate regarding the assessment of clients diagnosed
with psychiatric problems?
A. Medical history is of little significance and can be eliminated from the nursing
assessment.
,B. Assessment provides a holistic view of the client including biopsychosocial
aspects.
C. Comprehensive assessments can be performed only by advanced practice
nurses.
D. Psychosocial evaluations are gained by subjective reports rather than
objective observations.
ANS: B
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.
Which nursing diagnosis should a nurse identify as being correctly formulated?
A. Schizophrenia R/T biochemical alterations AEB altered thought
B. Self-care deficit: hygiene R/T altered thought as AEB disheveled appearance
C. Depressed mood R/T multiple life stressors
D. Developmental disability R/T early-onset schizophrenia AEB hallucinations
ANS: B
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 client's condition, facilitating the choice of interventions.
, Which expected client outcome should a nurse identify as being correctly
formulated?
A. Client will feel happier by discharge.
B. Client will demonstrate two relaxation techniques.
C. Client will verbalize triggers to anger by end of session.
D. Client will initiate interaction with one peer during free time within 2 days.
ANS: D
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.
Which statement regarding nursing interventions should a nurse identify as
accurate?
A. Nursing interventions are independent from the treatment team's goals.
B. Nursing interventions are solely directed by written physician orders.
C. Nursing interventions occur independently but in concert with overall
treatment team goals.
D. Nursing interventions are standardized by policies and procedures.
ANS: C
The nurse should understand that nursing interventions occur independently but in
concert with overall treatment goals. Nursing interventions should be developed and
