C HAPTER 07: T HE N URSING P ROCESS AND
S TANDARDS OF C ARE
Halter: Varcarolis’ Foundations of Psychiatric -Mental Health Nursing: A
Clinical Approach, 9th Edition
MULTIPLE CHOICE
1. A nurse assesses an older adult client brought to the emergency
department (ED) by a famil y member. The client was wandering outside
saying, “I can’t find my way home.” The client is confused and unable to
answer questions. Select the nurse’s b est action.
a. Record the client’s answers to questions on the nursing assessment
form.
b. Ask an advanced practice nurse to perform the assessment
interview.
c. Call for a mental health advocate to maintain the client’s rights.
d. Obtain important information from th e famil y member.
ANS: D
When the client (primary source) is unable to provide information,
secondary sources should be used, in this case, the famil y member.
Later, more data may be obtained from other information sources
familiar with the client. An adv anced practice nurse is not needed for
this assessment; it is within the scope of practice of the staff nurse.
Calling a mental health advocate is unnecessary. See relationship to
audience response question.
PTS: 1 DIF: Cognitive Level: Appl y (Applicat ion)
TOP: Nursing Process: Assessment MSC: Client Needs:
Safe, Effective Care Environment
,2. A nurse asks a client, “If you had fever and vomiting for 3 days, what
would you do?” Which aspect of the mental status examination is the
nurse assessing?
a. Behavior
b. Cognition
c. Affect and mood
d. Perceptual disturbances
ANS: B
Assessing cognition involves determining a client’s judgment and
decision making. In this case, the nurse would expect a response of
“Call m y doctor” if the client’s cognition and judgment are i ntact. If
the client responds, “I would stop eating” or “I would just wait and see
what happened,” the nurse would conclude that judgment is impaired.
The other options refer to other aspects of the examination.
PTS: 1 DIF: Cognitive Level: Appl y (Appl ication)
TOP: Nursing Process: Assessment MSC: Client Needs:
Psychosocial Integrity
3. An adolescent asks a nurse conducting an assessment interview, “Why
should I tell you anything? You’ll just tell m y parents whatever you find
out.” Which response by the nurse is appropriate?
a. “That isn’t true. What you tell us is private and held in strict
confidence. Your parents have no right to know.”
b. “Yes, your parents may find out what you say, but it is important
that they know about your problems.”
c. “What you say about feelings is private, but some things, like
suicidal thinking, must be reported to the treatment team.”
d. “It sounds as though you are not reall y ready to work on your
problems and make changes.”
ANS: C
, Adolescents are very concerned with confidentialit y. The client has a
right to know that most information will be held in confidence, but that
certain material must be reported or shared with the treatment team,
such as threats of suicide, homicide, use of illegal drugs, or issues of
abuse. The incorrect responses are not true, will not inspire the
confidence of the client, or are confrontational.
PTS: 1 DIF: Cognitive Level: Appl y (Application)
TOP: Nursing Process: Implementation MSC: Client
Needs: Safe, Effective Care Environment
4. A nurse wants to assess an adult client’s recent memory. Which question
would best yield the desired information?
a. “Where did you go to elementary school?”
b. “What did you have for breakfast this morning?”
c. “Can you name the current president of the United States?”
d. “A few min utes ago, I told you m y name. Can you remember it?”
ANS: B
The client’s recall of a meal provides evidence of recent memory. Two
incorrect responses are useful to assess immediate and remote memory.
The other distracter assesses the client’s fund of know ledge.
PTS: 1 DIF: Cognitive Level: Appl y (Application)
TOP: Nursing Process: Assessment MSC: Client Needs:
Psychosocial Integrity
5. When a nurse assesses an older adult client, answers seem vague or
unrelated to the questions. The client also leans f orward and frowns,
listening intentl y to the nurse. An appropriate question for the nurse to
ask would be
a. “Are you having difficult y hearing when I speak?”
S TANDARDS OF C ARE
Halter: Varcarolis’ Foundations of Psychiatric -Mental Health Nursing: A
Clinical Approach, 9th Edition
MULTIPLE CHOICE
1. A nurse assesses an older adult client brought to the emergency
department (ED) by a famil y member. The client was wandering outside
saying, “I can’t find my way home.” The client is confused and unable to
answer questions. Select the nurse’s b est action.
a. Record the client’s answers to questions on the nursing assessment
form.
b. Ask an advanced practice nurse to perform the assessment
interview.
c. Call for a mental health advocate to maintain the client’s rights.
d. Obtain important information from th e famil y member.
ANS: D
When the client (primary source) is unable to provide information,
secondary sources should be used, in this case, the famil y member.
Later, more data may be obtained from other information sources
familiar with the client. An adv anced practice nurse is not needed for
this assessment; it is within the scope of practice of the staff nurse.
Calling a mental health advocate is unnecessary. See relationship to
audience response question.
PTS: 1 DIF: Cognitive Level: Appl y (Applicat ion)
TOP: Nursing Process: Assessment MSC: Client Needs:
Safe, Effective Care Environment
,2. A nurse asks a client, “If you had fever and vomiting for 3 days, what
would you do?” Which aspect of the mental status examination is the
nurse assessing?
a. Behavior
b. Cognition
c. Affect and mood
d. Perceptual disturbances
ANS: B
Assessing cognition involves determining a client’s judgment and
decision making. In this case, the nurse would expect a response of
“Call m y doctor” if the client’s cognition and judgment are i ntact. If
the client responds, “I would stop eating” or “I would just wait and see
what happened,” the nurse would conclude that judgment is impaired.
The other options refer to other aspects of the examination.
PTS: 1 DIF: Cognitive Level: Appl y (Appl ication)
TOP: Nursing Process: Assessment MSC: Client Needs:
Psychosocial Integrity
3. An adolescent asks a nurse conducting an assessment interview, “Why
should I tell you anything? You’ll just tell m y parents whatever you find
out.” Which response by the nurse is appropriate?
a. “That isn’t true. What you tell us is private and held in strict
confidence. Your parents have no right to know.”
b. “Yes, your parents may find out what you say, but it is important
that they know about your problems.”
c. “What you say about feelings is private, but some things, like
suicidal thinking, must be reported to the treatment team.”
d. “It sounds as though you are not reall y ready to work on your
problems and make changes.”
ANS: C
, Adolescents are very concerned with confidentialit y. The client has a
right to know that most information will be held in confidence, but that
certain material must be reported or shared with the treatment team,
such as threats of suicide, homicide, use of illegal drugs, or issues of
abuse. The incorrect responses are not true, will not inspire the
confidence of the client, or are confrontational.
PTS: 1 DIF: Cognitive Level: Appl y (Application)
TOP: Nursing Process: Implementation MSC: Client
Needs: Safe, Effective Care Environment
4. A nurse wants to assess an adult client’s recent memory. Which question
would best yield the desired information?
a. “Where did you go to elementary school?”
b. “What did you have for breakfast this morning?”
c. “Can you name the current president of the United States?”
d. “A few min utes ago, I told you m y name. Can you remember it?”
ANS: B
The client’s recall of a meal provides evidence of recent memory. Two
incorrect responses are useful to assess immediate and remote memory.
The other distracter assesses the client’s fund of know ledge.
PTS: 1 DIF: Cognitive Level: Appl y (Application)
TOP: Nursing Process: Assessment MSC: Client Needs:
Psychosocial Integrity
5. When a nurse assesses an older adult client, answers seem vague or
unrelated to the questions. The client also leans f orward and frowns,
listening intentl y to the nurse. An appropriate question for the nurse to
ask would be
a. “Are you having difficult y hearing when I speak?”
