Chapter 01: Me, Meds, Milieu
v v v v
Steele: Keltner’s Psychiatric Nursing, 9th Edition
v v v v v
MULTIPLEvCHOICE
1. Avnewlyvlicensedvnursevasksvavnursingvrecruitervforvavdescriptionvofvnursingvpracticevinvthevp
sychiatricvsetting.vWhatv isvthevnursevrecruiter‘svbestvresponse?
a. ―Thevnursevprimarilyvservesvinvavsupportivevrolevtovmembersvofvthevhealthvcare
deliveryvteam.‖
b. ―Thevmultidisciplinaryvapproachveliminatesvthevneedvtovclearlyvdefinevthe
responsibilitiesvofvnursingvinvsuchvavsetting.‖
c. ―Nursingvactionsvarevidentifiedvbyvthevinstitutionvthatvdistinguishesvnursingvfrom
othervmentalvhealthvprofessions.‖
d. ―Nursingvoffersvuniquevcontributionsvtovthevpsychotherapeuticvmanagementvof
psychiatricv patients.‖
ANS:v D
Professionalvrolevoverlapvcannotvbevdenied;vhowever,vnursingvisvuniquevinvitsvfocusvonvandvappl
icationvofvpsychotherapeuticvmanagement.vNeithervthevfacilityvnorvthevmultidisciplinaryvteamvde
finevthevprofessionalvresponsibilitiesvofvitsvmembersvbutvrathervutilizesvtheirvuniquevskillsvtovpro
videvholisticvcare.vIdeally,vallvteamvmembersvsupportveachvothervandvhavevfunctionsvwithinvthevt
eam.
DIF: Cognitivevlevel:vAnalyzing
TOP:v Nursingvprocess:vImplementationvMSC:v ClientvNeeds:vSafe,vEffectivev
CarevEnvironment
2. Whichvcomponentvofvthevnursingvprocessvwillvthevnursevfocusvuponvtovaddressvthevr
esponsibilityvtovmatchvindividualvpatientvneedsvwithvappropriatevservices?
a. Planning
b. Evaluation
c. Assessment
d. Implementation
ANS:v C
Propervassessmentvisvcriticalvforvbeingvablevtovdeterminevthevappropriatevlevelvofvservicesvthatvwi
llvprovidevoptimalvcarevwhilevconsideringvpatientvinputvandvatvthevlowestvcost.vPlanningvandvimp
lementationvutilizesvthevassessmentvdatavtovidentifyvandvexecutevactionsv(treatmentvplan)vthatvwi
llvprovidevappropriatevcare.vEvaluationvvalidatesvtheveffectivenessvofvthevtreatmentvplan.
DIF: Cognitivevlevel:vApplying
TOP:v Nursingvprocess:vAssessmentvMSC:v ClientvNeeds:vSafe,vEffectivev
CarevEnvironment
3. Anvadultvdiagnosedvwithvparanoidvschizophreniavfrequentlyvexperiencesvauditoryvhallucinat
ionsvandvwalksvaboutvthevunit,vmuttering.vWhichvnursingvactionvdemonstratesvthevnurse‘svun
derstandingvofveffectivevpsychotherapeuticvmanagementvofvthisvclient?
a. Discussingvthevdiseasevprocessvofvschizophreniavwithvthevclientvandvtheirvdomestic
partner
b. Minimizingvcontactvbetweenvthisvpatientvandvothervpatientsvtovassurevavstress-free
milieu
c. AdministeringvPRNvmedicationvwhenvfirstvobservingvthevevidencevthatvthevclient
, mayvbevhallucinating
d. Independentlyvdeterminingvthatvbehaviorvmodificationvisvappropriatevtovdecrease
thevclient‘svparanoidvthoughts
ANS:v A
Anvunderstandingvofvpsychopathologyvisvthevfoundationvonvwhichvthevthreevcomponentsvofvpsy
chotherapeuticvmanagementvrest;vitvfacilitatesvtherapeuticvcommunicationvandvprovidesvavbasisvf
orvunderstandingvpsychopharmacologyvandvmilieuvmanagement.vMinimizingvcontactvbetweenvt
hevpatientvandvothersvandvadministeringvPRNvmedicationvindiscriminatelyvarevnontherapeuticvi
nterventions.vUsingvbehaviorvmodificationvtovdecreasevthevfrequencyvofvhallucinationsvwouldvn
eedvtovbevincorporatedvintovthevplanvofvcarevbyvthevcarevteam.
DIF: Cognitivevlevel:vApplying
TOP:v Nursingvprocess:vImplementationvMSC:v ClientvNeeds:vSafe,vEffectivev
CarevEnvironment
4. Anvadultvdiagnosedvwithvchronicvdepressionvisvhospitalizedvaftervavsuicidevattempt.vWhichvi
nterventionvisvcriticalvinvassuringvlong-
term,veffectivevclientvcarevasvdescribedvbyvpsychotherapeuticvmanagement?
a. Involvementvinvgroupvtherapies
b. Focusvofvclosevsupervisionvbyvthevunitvstaff
c. Maintainingveffectivevcommunicationvwithvsupportvsystem
d. Frequentlyvscheduledvone-on-onevtimevwithvnursingvstaff
ANS:v D
Avcriticalvelementvofvpsychotherapeuticvmanagementvisvthevpresencevofvavtherapeutic
nurse-patientvrelationship.vOne-on-
onevtimevwithvnursingvstaffvwillvhelpvinvestablishingvthisvconnection.vWhilevthevothervoptionsvarev
appropriatevandvclientvcentered,vthevnurse-clientvrelationvisvcriticalvinvthevlong-
termvdeliveryvofvqualityveffectivevcarevtovthisvclient.
DIF: Cognitivevlevel:vApplying
TOP:v Nursingvprocess:vImplementationvMSC:v ClientvNeeds:vPsychosocialvInt
egrity
5. Avpatient‘svhaloperidolvdosagevwasvreducedv2vweeksvagovtovdecreasevsideveffects.vWhatvas
sessmentvquestionvdemonstratesvthevnurse‘svunderstandingvofvthevresultingvneedsvofvthevcli
ent?
a. ―Willvyouvhavevanyvdifficultyvgettingv yourvprescriptionvrefilled?‖
b. ―Havev youvbegunvexperiencingvanyvformsvofvhallucinations?‖
c. ―Whatvdovyouvexpectvwillvoccurvsincevthevdosagevhasvbeenvreduced?‖
d. ―WhatvcanvIvdovtovhelpv youvmanagevthisvreductionvinvhaloperidolvtherapy?‖
ANS:v B
Itvwillvbevnecessaryvforvthevnursevtovassessvforvexacerbationvofvthevpatient‘svsymptomsvofvpsych
osisvasvwellvasvforvavlesseningvofvsideveffects.vDosagevdecreasevmightvleadvtovthevreturnvorvworse
ningvofvpositivevsymptomsvsuchvasvhallucinationsvandvdelusions,vandvnegativevsymptomsvsuchv
asvbluntedvaffect,vsocialvwithdrawal,vandvpoorvgrooming.vWhilevthevothervoptionsvmayvbevappro
priatevassessmentvquestions,vtheyvarevnotvdirectedvatvthevcurrentvneedsvofvthevclientvwhichvisvthevi
dentificationvofvemergingvpsychoticvbehaviors.
DIF: Cognitivevlevel:vAnalyzing
TOP:v Nursingvprocess:vAssessmentvMSC:v ClientvNeeds:vPhysiologicvInte
grity
,6. Whichvstatementvformsvthevfoundationvuponvwhichvavnursevshouldvbasevthevimplementationvofvp
sychotherapeuticvmanagementvtovthevcarevofvavpatientvwithvmentalvillness?
a. Thevnurse‘svrolevinvclientvcarevisvsupportedvbyvthevmultidisciplinaryvteam.
b. Omittingvanyvonevcomponentvwillvcompromisevtheveffectivenessvofvthevtreatment.
c. Thevmostvimportantvelementvofvpsychotherapeuticvmanagementvisvdrugvtherapy.
d. Avtherapeuticvnurse-patientvrelationshipvisvthevmostvimportantvaspectvofvtreatment.
ANS:v B
Whenvonevelementvisvmissing,vtreatmentvisvusuallyvcompromised.vNovsinglevelementvisvmorevi
mportantvthanvthevothers;vhowever,vpatients‘vneedsvgovernvthevapplicationvofvthevcomponentsva
ndvpermitvjudiciousvuse.vThevremainingvoptionsvidentifyvcomponentsvofvthevpsychotherapeuticv
managementvprocess.
DIF: Cognitivevlevel:vAnalyzing
TOP:v Nursingvprocess:vAnalysisvMSC:v ClientvNeeds:vSafe,vEffectivev
CarevEnvironment
7. Whichvstatementvmostvaccuratelyvdescribesvavnurse‘svrolevregardingvpsychopharmacology?
a. ―YouvwillvneedvtovfrequentlyvmakevdecisionsvregardingvthevadministrationvofvPRN
medicationsvtovhelpvthevclientvmanagevanger.‖
b. ―It‘svavnursingvresponsibilityvtovadjustv avmedicationvdosevtovassureveffectivevpatientvres
ponses.‖
c. ―Nursesvadministersvmedicationsvwhilevevaluatingv drugveffectivenessvisvavmedicalvres
ponsibility.‖
d. ―Tovbestvassurevappropriatevresponse,vavpatient‘svquestionsvaboutvdrugvtherapyvshould
vbe vreferredvtovthe vpsychiatrist.‖
ANS:v A
NursingvassessmentvandvanalysisvofvdatavmightvsuggestvthevneedvforvPRNvmedicationvasvpatientv
anxietyvincreasesvorvpsychoticvsymptomsvbecomevmorevacute.vThevnursevisvthevhealthvteamvme
mbervwhovmakesvthisvdetermination.vNursesvarevresponsiblevforvmonitoringvdrugveffectivenessv
asvwellvasvadministeringvmedication.vNursesvshouldvassumevresponsibilityvforvteachingvpatientsv
aboutvthevsideveffectsvofvmedications.vNursesvcannotvaltervprescribedvdosagesvofvmedicationsvunl
essvtheyvhavevprescriptivevprivileges.
DIF: Cognitivevlevel:vAnalyzing
TOP:v Nursingvprocess:vAnalysisvMSC:v ClientvNeeds:vSafe,vEffectivev
CarevEnvironment
8. Whenvconsideringvenvironmentalvaspectsvofvmilieuvmanagement,vwhichvinterventionvhasvthevh
ighestvpriorityvforvavclientvadmittedvaftervavfailedvsuicidevattempt?
a. Sendingvthevclient‘svnewvmedicationvprescriptionsvtovthevpharmacy
b. Assigningvavstaffvmembervtovone-on-onevobservationvofvthevclient
c. Orientingvthevclientvtovthevmilieu‘svpublicvandvprivatevspaces
d. Havingvallvpotentiallyvdangerousvitemsvremovedvfromvthevclient‘svbelongings
ANS:v B
Milieuvmanagementvprovidesvavproactivevapproachvtovcare.vSafetyvoverridesvallvothervdimensio
nsvofvthevmilieu.vInitiationvofvsuicidevprecautionsvarevthevpriorityvforvthisvclient.vAllvthevremainin
gvoptionsvarevappropriatevbutvnonevprotectvthevclientvfromvthevriskvofvanothervattemptvtovself-
harmvasveffectivelyvasvone-on-onevobservationvasvpartvofvsuicidevprecautions.
DIF: Cognitivevlevel:vAnalyzing TOP:v Nursingvprocess:vImplementation
, MSC:v ClientvNeeds:vSafe,vEffectivevCarevEnvironment
9. Thevimplementationvofvwhichvunitvpolicyvdirectedvatvmilieuvbalancevwouldvreflectvavneedvforvr
econsiderationvonvthevpartvofvthevtreatmentvteam?
a. Allvclientsvwillvreceivevverbalvandvwrittenvinformationvexplainingvunitvrules.
b. Unitvclientsvwillvengagevinvallvunitvactivitiesvtovassurevinteractionvwithvbothvstaffvand
vothervclients.
c. Allvclientsvwillvbevuniformlyvexpectedvtovpresentvthemselvesvinvavnonviolentvmanne
rvtovbothvstaffvandvothervclients.
d. Atvtimesvofvunitvstress,vclientvwillvreturnvtovtheirvrooms.
ANS:v B
Thevsituationvdescribedvsuggestsvavmilieuvinvwhichvpatientsvhavevnovtimevforvplannedvtherapeuti
cvencountersvwithvstaff;vhence,vitvisvavmilieuvlackingvbalance.vThevremainingvoptionsvaddressvuni
tvnorms,vlimitvsetting,vandvenvironmentalvmodificationsvthatvarevreasonablevandvwillvcontributevto
v avtherapeuticv milieu.
DIF: Cognitivevlevel:vEvaluating
TOP:v Nursingvprocess:vEvaluationvMSC:v ClientvNeeds:vSafe,vEffectivev
CarevEnvironment
10. Whichvinterventionvshouldvthevnursevimplementvwhenvfocusingvonvcommunicatingvt
herapeuticallyvwithvavclient?
a. Explainingvtovthevclientvwhyvtheyvwillvneedvtovaskvforvavrazor
b. Providingvthevclientvwithvoptionsvtovhelpvachievevsmokingvcessation
c. Encouragingvthevclientvtovidentifyvpersonalvstressors
d. Assuringvthevclientvthatvtheyvcanvreceivevtelephonevcallvonvthevunitvtelephone
ANS:v C
Avnursevusesvtherapeuticvcommunicationvtechniquesvasvpartvofvthevtherapeuticvnurse-
patientvrelationship.vAnvexamplevofvsuchvcommunicationvisvprovidingvthevclientv withvanvopport
unityvtovsafelyvidentifyvpersonalvstressors.vThevremainingvoptionsvaddressvsafety,vbalance,vandvn
ormsvassociatedvwithvtheirvcare.
DIF: Cognitivevlevel:vApplying
TOP:v Nursingvprocess:vImplementationvMSC:v ClientvNeeds:vPsychosocialvInt
egrity
11. Duringvthevriskvassessmentvphasevofvcarevforvavpsychiatricvpatient,vwhatvisvthevnurse‘svprimaryvg
oal?
a. Makingvanvinitialvassessment
b. Confirmingvthevpatient‘svproblem
c. Assessingvpotentialvdangerousnessvtovselfvorvothers
d. Determiningvthevlevelvofvsupervisionvneededvforvthevpatient
ANS:v C
Riskvassessmentvinvolvesvlookingvatvdangerousnessvtovselfvorvothers,vthevdegreevofvdisability,va
ndvwhethervorvnotvthevindividualvisvacutelyvpsychoticvtovdeterminevthevfeasibilityvofvcommunit
y-basedvcarevversusvhospital-
basedvcare.vRiskvassessmentvusuallyvfollowsvthevinitialvassessment.vConfirmationvofvthevpatient
‘svproblemvisvnotvpartvofvthevriskvassessmentvprotocol.vArrangingventryvintovthevmentalvhealthvsy
stemvwillvfollowvriskvassessmentvifvthevpatientvisvassessedvasvneedingvservice.
DIF: Cognitivevlevel:vApplying TOP:v Nursingvprocess:vAssessment
v v v v
Steele: Keltner’s Psychiatric Nursing, 9th Edition
v v v v v
MULTIPLEvCHOICE
1. Avnewlyvlicensedvnursevasksvavnursingvrecruitervforvavdescriptionvofvnursingvpracticevinvthevp
sychiatricvsetting.vWhatv isvthevnursevrecruiter‘svbestvresponse?
a. ―Thevnursevprimarilyvservesvinvavsupportivevrolevtovmembersvofvthevhealthvcare
deliveryvteam.‖
b. ―Thevmultidisciplinaryvapproachveliminatesvthevneedvtovclearlyvdefinevthe
responsibilitiesvofvnursingvinvsuchvavsetting.‖
c. ―Nursingvactionsvarevidentifiedvbyvthevinstitutionvthatvdistinguishesvnursingvfrom
othervmentalvhealthvprofessions.‖
d. ―Nursingvoffersvuniquevcontributionsvtovthevpsychotherapeuticvmanagementvof
psychiatricv patients.‖
ANS:v D
Professionalvrolevoverlapvcannotvbevdenied;vhowever,vnursingvisvuniquevinvitsvfocusvonvandvappl
icationvofvpsychotherapeuticvmanagement.vNeithervthevfacilityvnorvthevmultidisciplinaryvteamvde
finevthevprofessionalvresponsibilitiesvofvitsvmembersvbutvrathervutilizesvtheirvuniquevskillsvtovpro
videvholisticvcare.vIdeally,vallvteamvmembersvsupportveachvothervandvhavevfunctionsvwithinvthevt
eam.
DIF: Cognitivevlevel:vAnalyzing
TOP:v Nursingvprocess:vImplementationvMSC:v ClientvNeeds:vSafe,vEffectivev
CarevEnvironment
2. Whichvcomponentvofvthevnursingvprocessvwillvthevnursevfocusvuponvtovaddressvthevr
esponsibilityvtovmatchvindividualvpatientvneedsvwithvappropriatevservices?
a. Planning
b. Evaluation
c. Assessment
d. Implementation
ANS:v C
Propervassessmentvisvcriticalvforvbeingvablevtovdeterminevthevappropriatevlevelvofvservicesvthatvwi
llvprovidevoptimalvcarevwhilevconsideringvpatientvinputvandvatvthevlowestvcost.vPlanningvandvimp
lementationvutilizesvthevassessmentvdatavtovidentifyvandvexecutevactionsv(treatmentvplan)vthatvwi
llvprovidevappropriatevcare.vEvaluationvvalidatesvtheveffectivenessvofvthevtreatmentvplan.
DIF: Cognitivevlevel:vApplying
TOP:v Nursingvprocess:vAssessmentvMSC:v ClientvNeeds:vSafe,vEffectivev
CarevEnvironment
3. Anvadultvdiagnosedvwithvparanoidvschizophreniavfrequentlyvexperiencesvauditoryvhallucinat
ionsvandvwalksvaboutvthevunit,vmuttering.vWhichvnursingvactionvdemonstratesvthevnurse‘svun
derstandingvofveffectivevpsychotherapeuticvmanagementvofvthisvclient?
a. Discussingvthevdiseasevprocessvofvschizophreniavwithvthevclientvandvtheirvdomestic
partner
b. Minimizingvcontactvbetweenvthisvpatientvandvothervpatientsvtovassurevavstress-free
milieu
c. AdministeringvPRNvmedicationvwhenvfirstvobservingvthevevidencevthatvthevclient
, mayvbevhallucinating
d. Independentlyvdeterminingvthatvbehaviorvmodificationvisvappropriatevtovdecrease
thevclient‘svparanoidvthoughts
ANS:v A
Anvunderstandingvofvpsychopathologyvisvthevfoundationvonvwhichvthevthreevcomponentsvofvpsy
chotherapeuticvmanagementvrest;vitvfacilitatesvtherapeuticvcommunicationvandvprovidesvavbasisvf
orvunderstandingvpsychopharmacologyvandvmilieuvmanagement.vMinimizingvcontactvbetweenvt
hevpatientvandvothersvandvadministeringvPRNvmedicationvindiscriminatelyvarevnontherapeuticvi
nterventions.vUsingvbehaviorvmodificationvtovdecreasevthevfrequencyvofvhallucinationsvwouldvn
eedvtovbevincorporatedvintovthevplanvofvcarevbyvthevcarevteam.
DIF: Cognitivevlevel:vApplying
TOP:v Nursingvprocess:vImplementationvMSC:v ClientvNeeds:vSafe,vEffectivev
CarevEnvironment
4. Anvadultvdiagnosedvwithvchronicvdepressionvisvhospitalizedvaftervavsuicidevattempt.vWhichvi
nterventionvisvcriticalvinvassuringvlong-
term,veffectivevclientvcarevasvdescribedvbyvpsychotherapeuticvmanagement?
a. Involvementvinvgroupvtherapies
b. Focusvofvclosevsupervisionvbyvthevunitvstaff
c. Maintainingveffectivevcommunicationvwithvsupportvsystem
d. Frequentlyvscheduledvone-on-onevtimevwithvnursingvstaff
ANS:v D
Avcriticalvelementvofvpsychotherapeuticvmanagementvisvthevpresencevofvavtherapeutic
nurse-patientvrelationship.vOne-on-
onevtimevwithvnursingvstaffvwillvhelpvinvestablishingvthisvconnection.vWhilevthevothervoptionsvarev
appropriatevandvclientvcentered,vthevnurse-clientvrelationvisvcriticalvinvthevlong-
termvdeliveryvofvqualityveffectivevcarevtovthisvclient.
DIF: Cognitivevlevel:vApplying
TOP:v Nursingvprocess:vImplementationvMSC:v ClientvNeeds:vPsychosocialvInt
egrity
5. Avpatient‘svhaloperidolvdosagevwasvreducedv2vweeksvagovtovdecreasevsideveffects.vWhatvas
sessmentvquestionvdemonstratesvthevnurse‘svunderstandingvofvthevresultingvneedsvofvthevcli
ent?
a. ―Willvyouvhavevanyvdifficultyvgettingv yourvprescriptionvrefilled?‖
b. ―Havev youvbegunvexperiencingvanyvformsvofvhallucinations?‖
c. ―Whatvdovyouvexpectvwillvoccurvsincevthevdosagevhasvbeenvreduced?‖
d. ―WhatvcanvIvdovtovhelpv youvmanagevthisvreductionvinvhaloperidolvtherapy?‖
ANS:v B
Itvwillvbevnecessaryvforvthevnursevtovassessvforvexacerbationvofvthevpatient‘svsymptomsvofvpsych
osisvasvwellvasvforvavlesseningvofvsideveffects.vDosagevdecreasevmightvleadvtovthevreturnvorvworse
ningvofvpositivevsymptomsvsuchvasvhallucinationsvandvdelusions,vandvnegativevsymptomsvsuchv
asvbluntedvaffect,vsocialvwithdrawal,vandvpoorvgrooming.vWhilevthevothervoptionsvmayvbevappro
priatevassessmentvquestions,vtheyvarevnotvdirectedvatvthevcurrentvneedsvofvthevclientvwhichvisvthevi
dentificationvofvemergingvpsychoticvbehaviors.
DIF: Cognitivevlevel:vAnalyzing
TOP:v Nursingvprocess:vAssessmentvMSC:v ClientvNeeds:vPhysiologicvInte
grity
,6. Whichvstatementvformsvthevfoundationvuponvwhichvavnursevshouldvbasevthevimplementationvofvp
sychotherapeuticvmanagementvtovthevcarevofvavpatientvwithvmentalvillness?
a. Thevnurse‘svrolevinvclientvcarevisvsupportedvbyvthevmultidisciplinaryvteam.
b. Omittingvanyvonevcomponentvwillvcompromisevtheveffectivenessvofvthevtreatment.
c. Thevmostvimportantvelementvofvpsychotherapeuticvmanagementvisvdrugvtherapy.
d. Avtherapeuticvnurse-patientvrelationshipvisvthevmostvimportantvaspectvofvtreatment.
ANS:v B
Whenvonevelementvisvmissing,vtreatmentvisvusuallyvcompromised.vNovsinglevelementvisvmorevi
mportantvthanvthevothers;vhowever,vpatients‘vneedsvgovernvthevapplicationvofvthevcomponentsva
ndvpermitvjudiciousvuse.vThevremainingvoptionsvidentifyvcomponentsvofvthevpsychotherapeuticv
managementvprocess.
DIF: Cognitivevlevel:vAnalyzing
TOP:v Nursingvprocess:vAnalysisvMSC:v ClientvNeeds:vSafe,vEffectivev
CarevEnvironment
7. Whichvstatementvmostvaccuratelyvdescribesvavnurse‘svrolevregardingvpsychopharmacology?
a. ―YouvwillvneedvtovfrequentlyvmakevdecisionsvregardingvthevadministrationvofvPRN
medicationsvtovhelpvthevclientvmanagevanger.‖
b. ―It‘svavnursingvresponsibilityvtovadjustv avmedicationvdosevtovassureveffectivevpatientvres
ponses.‖
c. ―Nursesvadministersvmedicationsvwhilevevaluatingv drugveffectivenessvisvavmedicalvres
ponsibility.‖
d. ―Tovbestvassurevappropriatevresponse,vavpatient‘svquestionsvaboutvdrugvtherapyvshould
vbe vreferredvtovthe vpsychiatrist.‖
ANS:v A
NursingvassessmentvandvanalysisvofvdatavmightvsuggestvthevneedvforvPRNvmedicationvasvpatientv
anxietyvincreasesvorvpsychoticvsymptomsvbecomevmorevacute.vThevnursevisvthevhealthvteamvme
mbervwhovmakesvthisvdetermination.vNursesvarevresponsiblevforvmonitoringvdrugveffectivenessv
asvwellvasvadministeringvmedication.vNursesvshouldvassumevresponsibilityvforvteachingvpatientsv
aboutvthevsideveffectsvofvmedications.vNursesvcannotvaltervprescribedvdosagesvofvmedicationsvunl
essvtheyvhavevprescriptivevprivileges.
DIF: Cognitivevlevel:vAnalyzing
TOP:v Nursingvprocess:vAnalysisvMSC:v ClientvNeeds:vSafe,vEffectivev
CarevEnvironment
8. Whenvconsideringvenvironmentalvaspectsvofvmilieuvmanagement,vwhichvinterventionvhasvthevh
ighestvpriorityvforvavclientvadmittedvaftervavfailedvsuicidevattempt?
a. Sendingvthevclient‘svnewvmedicationvprescriptionsvtovthevpharmacy
b. Assigningvavstaffvmembervtovone-on-onevobservationvofvthevclient
c. Orientingvthevclientvtovthevmilieu‘svpublicvandvprivatevspaces
d. Havingvallvpotentiallyvdangerousvitemsvremovedvfromvthevclient‘svbelongings
ANS:v B
Milieuvmanagementvprovidesvavproactivevapproachvtovcare.vSafetyvoverridesvallvothervdimensio
nsvofvthevmilieu.vInitiationvofvsuicidevprecautionsvarevthevpriorityvforvthisvclient.vAllvthevremainin
gvoptionsvarevappropriatevbutvnonevprotectvthevclientvfromvthevriskvofvanothervattemptvtovself-
harmvasveffectivelyvasvone-on-onevobservationvasvpartvofvsuicidevprecautions.
DIF: Cognitivevlevel:vAnalyzing TOP:v Nursingvprocess:vImplementation
, MSC:v ClientvNeeds:vSafe,vEffectivevCarevEnvironment
9. Thevimplementationvofvwhichvunitvpolicyvdirectedvatvmilieuvbalancevwouldvreflectvavneedvforvr
econsiderationvonvthevpartvofvthevtreatmentvteam?
a. Allvclientsvwillvreceivevverbalvandvwrittenvinformationvexplainingvunitvrules.
b. Unitvclientsvwillvengagevinvallvunitvactivitiesvtovassurevinteractionvwithvbothvstaffvand
vothervclients.
c. Allvclientsvwillvbevuniformlyvexpectedvtovpresentvthemselvesvinvavnonviolentvmanne
rvtovbothvstaffvandvothervclients.
d. Atvtimesvofvunitvstress,vclientvwillvreturnvtovtheirvrooms.
ANS:v B
Thevsituationvdescribedvsuggestsvavmilieuvinvwhichvpatientsvhavevnovtimevforvplannedvtherapeuti
cvencountersvwithvstaff;vhence,vitvisvavmilieuvlackingvbalance.vThevremainingvoptionsvaddressvuni
tvnorms,vlimitvsetting,vandvenvironmentalvmodificationsvthatvarevreasonablevandvwillvcontributevto
v avtherapeuticv milieu.
DIF: Cognitivevlevel:vEvaluating
TOP:v Nursingvprocess:vEvaluationvMSC:v ClientvNeeds:vSafe,vEffectivev
CarevEnvironment
10. Whichvinterventionvshouldvthevnursevimplementvwhenvfocusingvonvcommunicatingvt
herapeuticallyvwithvavclient?
a. Explainingvtovthevclientvwhyvtheyvwillvneedvtovaskvforvavrazor
b. Providingvthevclientvwithvoptionsvtovhelpvachievevsmokingvcessation
c. Encouragingvthevclientvtovidentifyvpersonalvstressors
d. Assuringvthevclientvthatvtheyvcanvreceivevtelephonevcallvonvthevunitvtelephone
ANS:v C
Avnursevusesvtherapeuticvcommunicationvtechniquesvasvpartvofvthevtherapeuticvnurse-
patientvrelationship.vAnvexamplevofvsuchvcommunicationvisvprovidingvthevclientv withvanvopport
unityvtovsafelyvidentifyvpersonalvstressors.vThevremainingvoptionsvaddressvsafety,vbalance,vandvn
ormsvassociatedvwithvtheirvcare.
DIF: Cognitivevlevel:vApplying
TOP:v Nursingvprocess:vImplementationvMSC:v ClientvNeeds:vPsychosocialvInt
egrity
11. Duringvthevriskvassessmentvphasevofvcarevforvavpsychiatricvpatient,vwhatvisvthevnurse‘svprimaryvg
oal?
a. Makingvanvinitialvassessment
b. Confirmingvthevpatient‘svproblem
c. Assessingvpotentialvdangerousnessvtovselfvorvothers
d. Determiningvthevlevelvofvsupervisionvneededvforvthevpatient
ANS:v C
Riskvassessmentvinvolvesvlookingvatvdangerousnessvtovselfvorvothers,vthevdegreevofvdisability,va
ndvwhethervorvnotvthevindividualvisvacutelyvpsychoticvtovdeterminevthevfeasibilityvofvcommunit
y-basedvcarevversusvhospital-
basedvcare.vRiskvassessmentvusuallyvfollowsvthevinitialvassessment.vConfirmationvofvthevpatient
‘svproblemvisvnotvpartvofvthevriskvassessmentvprotocol.vArrangingventryvintovthevmentalvhealthvsy
stemvwillvfollowvriskvassessmentvifvthevpatientvisvassessedvasvneedingvservice.
DIF: Cognitivevlevel:vApplying TOP:v Nursingvprocess:vAssessment
