A psychiatric nurse discusses rules of the therapeutic milieu and patients’ rights with a
newly admitted patient. Which rights should be included? The right to (Select all that apply) have visitors. confidentiality. a private room. complain about inadequate care. select the nurse assigned to their care.
Which statements by patients diagnosed with a serious mental illness best demonstrate that
the case manager has established an effective long-term relationship? “My case manager
(Select all that apply) talks in language I can understand.” helps me keep track of my medication.” gives me little gifts from time to time.” looks at me as a whole person with many needs.” let me do whatever I choose without interfering.”.
Which statements most clearly reflect the stigma of mental illness? (Select all that apply.) “Many mental illnesses are hereditary.” “Mental illness can be evidence of a brain disorder. “People claim mental illness so they can get disability checks. “If people with mental illness went to church, their symptoms would disappear.” “If people with mental illness went to church, their symptoms would disappear.”.
A person in the community asks, “People with mental illnesses went to state hospitals in
earlier times. Why has that changed?” Select the nurse’s accurate responses. (Select all that
apply.) “Science has made significant improvements in drugs for mental illness, so now
many persons may live in their communities.” “There’s now a better selection of less restrictive treatment options available in
communities to care for people with mental illness.” “National rates of mental illness have declined significantly. There actually is not a
need for state institutions anymore.” “Most psychiatric institutions were closed because of serious violations of
patients’ rights and unsafe conditions.” “Federal legislation and payment for treatment of mental illness has shifted the
focus to community rather than institutional settings.”.
A patient diagnosed with schizophrenia lives in the community. On a home visit, the
community psychiatric nurse case manager learns that the patient:
• wants to attend an activity group at the mental health outreach center.
• is worried about being able to pay for the therapy.
• does not know how to get from home to the outreach center.
• has an appointment to have blood work at the same time an activity group meets.
• wants to attend services at a church that is a half-mile from the patient’s home.
Which tasks are part of the role of a community mental health nurse? (Select all that apply.) Rearranging conflicting care appointments Negotiating the cost of therapy for the patient Arranging transportation to the outreach cente Accompanying the patient to church services weekly Monitoring to ensure the patient’s basic needs are met.
Which Western cultural feature may result in establishing unrealistic outcomes for patients
of other cultural groups? Interdependence Present orientation Flexible perception of time Direct confrontation to solve problems.
A psychiatric nurse leads a medication education group for Hispanic patients. This nurse
holds a Western worldview and uses pamphlets as teaching tools. Groups are short and
concise. After the group, the patients are most likely to believe the nurse was uncaring. the session was effective. the teaching was efficient they were treated respectfully.
To provide culturally competent care, the nurse should accurately interpret the thinking of individual patients predict how a patient may perceive treatment interventions. formulate interventions to reduce the patient’s ethnocentrism identify strategies that fit within the cultural context of the patient.
A black patient, originally from Haiti, has a diagnosis of major depressive disorder. A
colleague tells the nurse, “This patient often looks down and is reluctant to share feelings.
However, I’ve observed the patient spontaneously interacting with other black patients.”
Select the nurse’s best response. “Black patients depend on the church for support. Have you consulted the patient’s
pastor?” “Encourage the patient to talk in a group setting. It will be less intimidating than
one-to-one interaction.” “Don’t take it personally. Black patients often have a resentful attitude that takes a
long time to overcome.” “The patient may have difficulty communicating in English. Have you considered
using a cultural broker?”.
A Haitian patient diagnosed with major depressive disorder tells the nurse, “There’s nothing
you can do. This is a punishment. The only thing I can do is see a healer.” The culturally
aware nurse assesses that the patient has delusions of persecution. has likely been misdiagnosed with depression. may believe the distress is the result of a curse or spell. feels hopeless and helpless related to an unidentified cause.
A group activity on an inpatient psychiatric unit is scheduled to begin at 1000. A patient,
who was recently discharged from U.S. Marine Corps, arrives at 0945. Which analysis best
explains this behavior? The patient wants to lead the group and give directions to others. The patient wants to secure a chair that will be close to the group leader. The military culture values timeliness. The patient does not want to be late. The behavior indicates feelings of self-importance that the patient wants others to
appreciate.
A nurse in the clinic has a full appointment schedule. A Hispanic American patient arrives
at 1230 for a 1000 appointment. A Native American patient does not keep an appointment at
all. What understanding will improve the nurse’s planning? These patients are members of cultural groups that have a different view of time. immature and irresponsible in health care matters. acting-out feelings of anger toward the system. displaying passive-aggressive tendencies.
The sibling of an Asian American patient tells the nurse, “My sister needs help for pain. She
cries from the hurt.” Which understanding by the nurse will contribute to culturally
competent care for this patient? Persons of an Asian American heritage often express emotional distress with physical symptoms. will probably respond best to a therapist who is impersonal. will require prolonged treatment to stabilize these symptoms. should be given direct information about the diagnosis and prognosis.
Which communication strategy would be most effective for a nurse to use during an
assessment interview with an adult Native American patient? Open and friendly; ask direct questions; touch the patient’s arm or hand
occasionally for reassurance. Frequent nonverbal behaviors, such as gestures and smiles; make an unemotional
face to express negatives. Soft voice; break eye contact occasionally; general leads and reflective techniques. Stern voice; unbroken eye contact; minimal gestures; direct questions.
A Native American patient sadly describes a difficult childhood. The patient abused alcohol
as a teenager but stopped 10 years ago. The patient now says, “I feel stupid and good for
nothing. I don’t help my people.” How should the treatment team focus planning for this
patient? Psychopharmacological and somatic therapies should be central techniques. Apply a psychoanalytical approach, focused on childhood trauma. Depression and alcohol abuse should be treated concurrently. Use a holistic approach, including mind, body, and spirit.
A Native American patient describes a difficult childhood and dropping out of high school.
The patient abused alcohol as a teenager to escape feelings of isolation but stopped 10 years
ago. The patient now says, “I feel stupid. I’ve never had a good job. I don’t help my
people.” Which nursing diagnosis applies? Risk for other-directed violence Chronic low self-esteem Deficient knowledge Social isolation.
Which viewpoint of an Asian American family will most affect decision making about care? The father is the authority figure. The mother is head of the household. Women should make their own decisions. Emotional communication styles are desirable.
Which intervention best demonstrates that a nurse correctly understands the cultural needs
of a hospitalized Asian American patient diagnosed with a mental illness? Encouraging the family to attend community support groups Involving the patient’s family to assist with activities of daily living
Providing educational pamphlets to explain the patient’s mental illness Restricting homemade herbal remedies the family brings to the hospital.
A nurse speaks with family members of a Chinese American parent recently diagnosed with
major depressive disorder. Which comment by the nurse will the family find most
comforting? “The nursing staff will take good care of your parent.” pray with your parent several times a day.” teach your parent important self-care strategies.” educate your parent about safety information regarding medication.”.
A patient in the emergency department shows a variety of psychiatrical symptoms,
including restlessness and anxiety. The patient says, “I feel sad because evil spirits have
overtaken my mind.” Which worldview is most applicable to this individual? Eastern/balance Southern/holistic Western/scientific Indigenous/harmony.
A nurse prepares to teach important medication information to a patient of Mexican
heritage. How should the nurse manage the teaching environment? Stand very close to the patient while teaching. Maintain direct eye contact with the patient while teaching. Maintain a neutral emotional tone during the teaching session. Sit 4 feet or more from the patient during the teaching session.
A Chinese American patient diagnosed with an anxiety disorder says, “My problems began
when my energy became imbalanced.” The nurse asks for the patient’s ideas about how to
treat the imbalance. Which comment would the nurse expect from this patient? “My family will bring special foods to help me get well.” “I hope my health care provider will prescribe some medication to help me.”
“I think I would benefit from talking to other patients with a similar problem.” “I would like to have a native healer perform a ceremony to balance my energy.”.
An experienced psychiatric nurse plans to begin a new job in a community-based
medication clinic. The clinic sees culturally diverse patients. Which action should the nurse
take first to prepare for this position? Investigate cultural differences in patients’ responses to psychotropic medications. Contact the clinical nurse specialist for guidelines regarding cultural competence. Examine the literature on various health beliefs of members of diverse cultures. Complete an online continuing education offering about psychopharmacology.
A psychoeducational session will discuss medication management for a culturally diverse
group of patients. Group participants are predominantly members of minority cultures. Of
the four staff nurses below, which nurse should lead this group? Very young registered nurse Older, mature registered nurse Newly licensed registered nurse A registered nurse who is very thin.
A nurse wants to engage an interpreter for a severely anxious 21-year-old male who
immigrated to the United States 2 years ago. Of the four interpreters below who are
available and fluent in the patient’s language, which one should the nurse call? 65-year-old female professional interpreter 24-year-old male professional interpreter A member of the patient’s family The patient’s best friend.
A patient who has been hospitalized for 3 days with a serious mental illness says, “I’ve got
to get out of here and back to my job. I get 60 to 80 messages a day, and I’m getting behind
on my email correspondence.” What is this patient’s perspective about health and illness? Fateful, magical Eastern, holistic Western, biomedical Harmonious, religious.
A white patient of German descent rocks back and forth, grimaces, and rubs both temples.
What is the nurse’s best action? Assess the patient for extrapyramidal symptoms. Sit beside the patient and rock in sync. Offer to pray with the patient. Assess the patient for pain.
A Vietnamese patient’s family reports that the patient has wind illness. Which menu
selection will be most helpful for this patient? Iced tea Ice cream Warm broth Gelatin dessert.
A Mexican American patient puts a picture of the Virgin Mary on the bedside table. What is
the nurse’s best action? Move the picture so it is beside a window. Send the picture to the business office safe. Leave the picture where the patient placed it. Send the picture home with the patient’s family.
A nurse begins work in an agency that provides care to members of a minority ethnic
population. The nurse will be better able to demonstrate cultural competence after identifying culture-bound issues. implementing scientifically proven interventions. correcting inferior health practices of the population exploring commonly held beliefs and values of the population.
A nurse cares for a first-generation American whose family emigrated from Germany.
Which worldview about the source of knowledge would this patient likely have? Knowledge is acquired through use of affective or feeling senses. Science is the foundation of knowledge and proves something exists. Knowledge develops by striving for transcendence of the mind and body Knowledge evolves from an individual’s relationship with a supreme being.
The nurse administers medications to a culturally diverse group of patients on a psychiatric
unit. What expectation should the nurse have about pharmacokinetics? Patients of different cultural groups may metabolize medications at different rates. Metabolism of psychotropic medication is consistent among various cultural
groups. Differences in hepatic enzymes will influence the rate of elimination of
psychotropic medications. It is important to provide patients with oral and written literature about their
psychotropic medications.
A nurse prepares to assess a newly hospitalized patient who moved to the United States 6
months ago from Somalia. The nurse should first determine if the patient’s immunizations are current. the patient’s religious preferences. the patient’s specific ethnic group.
whether an interpreter is needed.
Which questions should the nurse ask to determine an individual’s worldview? (Select all
that apply. What is more important: the needs of an individual or the needs of a community? How would you describe an ideal relationship between individuals? How long have you lived at your present residence? Of what importance are possessions in your life? Do you speak any foreign languages.
Why is the study of culture so important for psychiatric nurses in the United States? (Select
all that apply.) Psychiatric nurses often practice in other countries. Psychiatric nurses must advocate for the traditions of the Western culture. Cultural competence helps protect patients from prejudice and discrimination. Patients should receive information about their illness and treatment in terms they
understand. Psychiatric nurses often interface with patients and their significant others over a
long period of time.
The nurse should be particularly alert to expression of psychological distress through
physical symptoms among patients whose cultural beliefs include (Select all that apply) mental illness reflects badly on the family. mental illness shows moral weakness. intergenerational conflict is common. the mind, body, and spirit are merged. food choices influence one’s health.
Which action by a psychiatric nurse best applies the ethical principle of autonomy? Exploring alternative solutions with the patient, who then makes a choice. Suggesting that two patients who were fighting be restricted to the unit. Intervening when a self-mutilating patient attempts to harm self. Staying with a patient demonstrating a high level of anxiety.
A nurse finds a psychiatric advance directive in the medical record of a patient currently
experiencing psychosis. The directive was executed during a period when the patient was
stable and competent. The nurse should review the directive with the patient to ensure it is current. ensure that the directive is respected in treatment planning. consider the directive only if there is a cardiac or respiratory arrest. encourage the patient to revise the directive in light of the current health problem.
Two hospitalized patients fight whenever they are together. During a team meeting, a nurse
asserts that safety is of paramount importance, so treatment plans should call for both
patients to be secluded to keep them from injuring each other. This assertion reinforces the autonomy of the two patients. violates the civil rights of both patients. represents the intentional tort of battery. correctly places emphasis on safety.
In a team meeting a nurse says, “I’m concerned about whether we are behaving ethically by
using restraint to prevent one patient from self-mutilation, while the care plan for another
self-mutilating patient requires one-on-one supervision.” Which ethical principle most
clearly applies to this situation? Beneficence Autonomy Fidelity Justice.
Select the example of a tort. The plan of care for a patient is not completed within 24 hours of the patient’s
admission. A nurse gives a prn dose of an antipsychotic drug to an agitated patient because the
unit is short-staffed. An advanced practice nurse recommends hospitalization for a patient who is
dangerous to self and others. A patient’s admission status changed from involuntary to voluntary after the
patient’s hallucinations subside.
What is the legal significance of a nurse’s action when a patient verbally refuses medication
and the nurse gives the medication over the patient’s objection? The nurse has been negligent. committed malpractice. fulfilled the standard of care. can be charged with battery.
Which nursing intervention demonstrates false imprisonment? A confused and combative patient says, “I’m getting out of here, and no one can
stop me.” The nurse restrains this patient without a health care provider’s order
and then promptly obtains an order. A patient has been irritating and attention seeking much of the day. A nurse escorts
the patient down the hall saying, “Stay in your room, or you’ll be put in seclusion. An involuntarily hospitalized patient with suicidal ideation runs out of the
psychiatric unit. The nurse rushes after the patient and convinces the patient to
return to the unit. An involuntarily hospitalized patient with homicidal ideation attempts to leave the
facility. A nurse calls the security team and uses established protocols to prevent
the patient from leaving.
Which patient meets criteria for involuntary hospitalization for psychiatric treatment? The
patient who is noncompliant with the treatment regimen. fraudulently files for bankruptcy. sold and distributed illegal drugs. threatens to harm self and others.
A nurse prepares to administer a scheduled intramuscular injection of an antipsychotic
medication to an outpatient diagnosed with schizophrenia. As the nurse swabs the site, the
patient shouts, “Stop! I don’t want to take that medicine anymore. I hate the side effects.”
Select the nurse’s best action. Assemble other staff for a show of force and proceed with the injection, using
restraint if necessary. Stop the medication administration procedure and say to the patient, “Tell me more
about the side effects you’ve been having.” Proceed with the injection but explain to the patient that there are medications that
will help reduce the unpleasant side effects. Say to the patient, “Since I’ve already drawn the medication in the syringe, I’m
required to give it, but let’s talk to the doctor about delaying next month’s dose.”.
A nurse is concerned that an agency’s policies are inadequate. Which understanding about
the relationship between substandard institutional policies and individual nursing practice
should guide nursing practice? Agency policies do not exempt an individual nurse of responsibility to practice
according to professional standards of nursing care. Agency policies are the legal standard by which a professional nurse must act and
therefore override other standards of care. Faced with substandard policies, a nurse has a responsibility to inform the
supervisor and discontinue patient care immediately. Interpretation of policies by the judicial system is rendered on an individual basis
and therefore cannot be predicted.
A newly admitted acutely psychotic patient is a private patient of the medical director and a
private-pay patient. To whom does the psychiatric nurse assigned to the patient owe the duty
of care? Medical director Hospital Profession Patient.
Which action by a nurse constitutes a breach of a patient’s right to privacy? Documenting the patient’s daily behavior during hospitalization Releasing information to the patient’s employer without consent Discussing the patient’s history with other staff during care planning Asking family to share information about a patient’s pre-hospitalization behavior.
An adolescent hospitalized after a violent physical outburst tells the nurse, “I’m going to kill
my father, but you can’t tell anyone.” Select the nurse’s best response. “You are right. Federal law requires me to keep clinical information private.” “I am obligated to share that information with the treatment team.” “Those kinds of thoughts will make your hospitalization longer.” “You should share this thought with your psychiatrist.”.
A voluntarily hospitalized patient tells the nurse, “Get me the forms for discharge. I want to
leave now.” Select the nurse’s best response. “I will get the forms for you right now and bring them to your room.” “Since you signed your consent for treatment, you may leave if you desire.” “I will get them for you, but let’s talk about your decision to leave treatment.” “I cannot give you those forms without your health care provider’s permission.
Insurance will not pay for continued private hospitalization of a mentally ill patient. The
family considers transferring the patient to a public hospital but expresses concern that the
patient will not get any treatment if transferred. Select the nurse’s most helpful reply. “By law, treatment must be provided. Hospitalization without treatment violates
patients’ rights.” “All patients in public hospitals have the right to choose both a primary therapist
and a primary nurse.” “You have a justifiable concern because the right to treatment extends only to
provision of food, shelter, and safety.” “Much will depend on other patients, because the right to treatment for a psychotic
patient takes precedence over the right to treatment of a patient who is stable.”.
Which individual diagnosed with mental illness may need emergency or involuntary
admission? The individual who resumes using heroin while still taking naltrexone (ReVia). reports hearing angels playing harps during thunderstorms. does not keep an outpatient appointment with the mental health nurse. throws a heavy plate at a waiter at the direction of command hallucinations.
A patient in alcohol rehabilitation reveals to the nurse, “I feel terrible guilt for sexually
abusing my 6-year-old before I was admitted.” Select the nurse’s most important action. Anonymously report the abuse by phone to the local child protection agency. Reply, “I’m glad you feel comfortable talking to me about it.” File a written report with the agency’s ethics committee. Respect nurse–patient relationship confidentiality.
A family member of a patient with delusions of persecution asks the nurse, “Are there any
circumstances under which the treatment team is justified in violating a patient’s right to
confidentiality?” The nurse should reply that confidentiality may be breached under no circumstances. at the discretion of the psychiatrist. when questions are asked by law enforcement. if the patient threatens the life of another person.
A new antidepressant is prescribed for an elderly patient diagnosed with major depressive
disorder, but the dose is more than the usual geriatric dose. The nurse should consult a reliable drug reference. teach the patient about possible side effects and adverse effects withhold the medication and confer with the health care provider. encourage the patient to increase oral fluids to reduce drug concentration.
A patient diagnosed with schizophrenia believes a local minister stirred evil spirits. The
patient threatens to bomb a local church. The psychiatrist notifies the minister. Select the
answer with the correct rationale. The psychiatrist released information without proper authorization. demonstrated the duty to warn and protect. violated the patient’s confidentiality. avoided charges of malpractice.
A patient experiencing psychosis became aggressive, struck another patient, and required
seclusion. Select the best documentation. Patient struck another patient who attempted to leave day room to go to bathroom.
Seclusion necessary at 1415. Plan: Maintain seclusion for 8 hours and keep these
two patients away from each other for 24 hours. Seclusion ordered by physician at 1415 after command hallucinations told the
patient to hit another patient. Careful monitoring of patient maintained during
period of seclusion. Seclusion ordered by MD for aggressive behavior. Begun at 1415. Maintained for
2 hours without incident. Outcome: Patient calmer and apologized for outburst. Patient pacing, shouting. Haloperidol 5 mg given PO at 1300. No effect by 1315.
At 1415 patient yelled, “I’ll punch anyone who gets near me,” and struck another
patient with fist. Physically placed in seclusion at 1420. Seclusion order obtained
from MD at 1430.
A person in the community asks, “Why aren’t people with mental illness kept in state
institutions anymore?” Select the nurse’s best response. “Less restrictive settings are available now to care for individuals with mental
illness.” “There are fewer persons with mental illness, so less hospital beds are needed.” “Most people with mental illness are still in psychiatric institutions.” “Psychiatric institutions violated patients’ rights.”.
A patient experiencing psychosis asks a psychiatric technician, “What’s the matter with
me?” The technician replies, “Nothing is wrong with you. You just need to use some selfcontrol.”
The nurse who overheard the exchange should take action based on the technician’s unauthorized disclosure of confidential clinical information. violation of the patient’s right to be treated with dignity and respect. the nurse’s obligation to report caregiver negligence. the patient’s right to social interaction.
Which documentation of a patient’s behavior best demonstrates a nurse’s observations? Isolates self from others. Frequently fell asleep during group. Vital signs stable. Calmer; more cooperative. Participated actively in group. No evidence of
psychotic thinking. Appeared to hallucinate. Frequently increased volume on television, causing
conflict with others. Wore four layers of clothing. States, “I need protection from evil bacteria trying to
pierce my skin.”.
After leaving work, a nurse realizes documentation of administration of a prn medication
was omitted. This off-duty nurse phones the nurse on duty and says, “Please document
administration of the medication for me. My password is alpha1.” The nurse receiving the
call should fulfill the request promptly. document the caller’s password. refer the matter to the charge nurse to resolve. report the request to the patient’s health care provider.
Which individual diagnosed with a mental illness may need involuntary hospitalization? An
individual who has a panic attack after her child gets lost in a shopping mall. with visions of demons emerging from cemetery plots throughout the community. who takes 38 acetaminophen tablets after the person’s stock portfolio becomes
worthless. diagnosed with major depression who stops taking prescribed antidepressant
medication.
An aide in a psychiatric hospital says to the nurse, “We don’t have time every day to help
each patient complete a menu selection. Let’s tell dietary to prepare popular choices and
send them to our unit.” Select the nurse’s best response. “Thanks for the suggestion, but that idea may not work because so many patients
take MAOI (monoamine oxidase inhibitor) antidepressants.” “Thanks for the idea, but it’s important to treat patients as individuals. Giving
choices is one way we can respect patients’ individuality.” “Thank you for the suggestion, but the patients’ bill of rights requires us to allow
patients to select their own diet.” “Thank you. That is a very good idea. It will make meal preparation easier for the
dietary department.”.
In order to release information to another health care facility or third party regarding a
patient diagnosed with a mental illness, the nurse must obtain a signed consent by the patient for release of information stating specific
information to be released. a verbal consent for information release from the patient and the patient’s guardian
or next of kin. permission from members of the health care team who participate in treatment
planning. approval from the attending psychiatrist to authorize the release of information.
In which situations would a nurse have the duty to intervene and report? (Select all that
apply.) A peer has difficulty writing measurable outcomes. A health care provider gives a telephone order for medication. A peer tries to provide patient care in an alcohol-impaired state. A team member violates relationship boundaries with a patient. A patient refuses medication prescribed by a licensed health care provider.
Which actions violate the civil rights of a psychiatric patient? The nurse (Select all that
apply) performs mouth checks after overhearing a patient say, “I’ve been spitting out my
medication.” begins suicide precautions before a patient is assessed by the health care provider. opens and reads a letter a patient left at the nurse’s station to be mailed. places a patient’s expensive watch in the hospital business office safe.
restrains a patient who uses profanity when speaking to the nurse.
A new staff nurse completes an orientation to the psychiatric unit. This nurse will expect to
ask an advanced practice nurse to perform which action for patients? Perform mental health assessment interviews. Prescribe psychotropic medication. Establish therapeutic relationships. Individualize nursing care plans.
A newly admitted patient diagnosed with major depressive disorder has gained 20 pounds
over a few months and has suicidal ideation. The patient has taken antidepressant
medication for 1 week without remission of symptoms. Select the priority nursing diagnosis. Imbalanced nutrition: more than body requirements Chronic low self-esteem Risk for suicid Hopelessness.
A patient diagnosed with major depressive disorder has lost 20 pounds in one month, has
chronic low self-esteem, and a plan for suicide. The patient has taken antidepressant
medication for 1 week. Which nursing intervention has the highest priority?
a. Implement suicide precautions. Implement suicide precautions. Offer high-calorie snacks and fluids frequently. Assist the patient to identify three personal strengths Observe patient for therapeutic effects of antidepressant medication.
The desired outcome for a patient experiencing insomnia is, “Patient will sleep for a
minimum of 5 hours nightly within 7 days.” At the end of 7 days, review of sleep data
shows the patient sleeps an average of 4 hours nightly and takes a 2-hour afternoon nap. The
nurse will document the outcome as consistently demonstrated. often demonstrated. sometimes demonstrated. never demonstrated.
The desired outcome for a patient experiencing insomnia is, “Patient will sleep for a
minimum of 5 hours nightly within 7 days.” At the end of 7 days, review of sleep data
shows the patient sleeps an average of 4 hours nightly and takes a 2-hour afternoon nap.
What is the nurse’s next action? Continue the current plan without changes. Remove this nursing diagnosis from the plan of care. Write a new nursing diagnosis that better reflects the problem Examine interventions for possible revision of the target date.
A patient begins a new program to assist with building social skills. In which part of the
plan of care should a nurse record the item, “Encourage patient to attend one
psychoeducational group daily”? Assessment Analysis Implementation Evaluation.
Before assessing a new patient, a nurse is told by another health care worker, “I know that
patient. No matter how hard we work, there isn’t much improvement by the time of
discharge.” The nurse’s responsibility is to document the other worker’s assessment of the patient. assess the patient based on data collected from all sources. validate the worker’s impression by contacting the patient’s significant other. discuss the worker’s impression with the patient during the assessment interview.
A patient presents to the emergency department with mixed psychiatric symptoms. The
admission nurse suspects the symptoms may be the result of a medical problem. Lab results
show elevated BUN (blood urea nitrogen) and creatinine. What is the nurse’s next best
action? Report the findings to the health care provider. Assess the patient for a history of renal problems. Assess the patient’s family history for cardiac problems. Arrange for the patient’s hospitalization on the psychiatric unit.
A patient states, “I’m not worth anything. I have negative thoughts about myself. I feel
anxious and shaky all the time. Sometimes I feel so sad that I want to go to sleep and never
wake up.” Which nursing intervention should have the highest priority? Self-esteem–building activities Anxiety self-control measures Sleep enhancement activities Suicide precautions.
Select the best outcome for a patient with the nursing diagnosis: Impaired social interaction
related to sociocultural dissonance as evidenced by stating, “Although I’d like to, I don’t
participate because I don’t speak the language very well.” Patient will show improved use of language. demonstrate improved social skills. become more independent in decision making. select and participate in one group activity per day.
Nursing behaviors associated with the implementation phase of nursing process are
concerned with participating in mutual identification of patient outcomes. gathering accurate and sufficient patient-centered data. comparing patient responses and expected outcomes. carrying out interventions and coordinating care.
Which statement made by a patient during an initial assessment interview should serve as
the priority focus for the plan of care? “I can always trust my family.” “It seems like I always have bad luck.” “You never know who will turn against you.” “I hear evil voices that tell me to do bad things.”.
Which entry in the medical record best meets the requirement for problem-oriented
charting? “A: Pacing and muttering to self. P: Sensory perceptual alteration related to
internal auditory stimulation. I: Given fluphenazine HCL 2.5 mg po at 0900 and
went to room to lie down. E: Calmer by 0930. Returned to lounge to watch TV.” “S: States, ‘I feel like I’m ready to blow up.’ O: Pacing hall, mumbling to self. A:
Auditory hallucinations. P: Offer haloperidol 2 mg po. I: Haloperidol 2 mg po
given at 0900. E: Returned to lounge at 0930 and quietly watched TV.” “Agitated behavior. D: Patient muttering to self as though answering an unseen
person. A: Given haloperidol 2 mg po and went to room to lie down. E: Patient
calmer. Returned to lounge to watch TV.” “Pacing hall and muttering to self as though answering an unseen person.
haloperidol 2 mg po administered at 0900 with calming effect in 30 minutes.
Stated, ‘I’m no longer bothered by the voices.’”.
A nurse assesses an older adult patient brought to the emergency department by a family
member. The patient was wandering outside saying, “I can’t find my way home.” The
patient is confused and unable to answer questions. Select the nurse’s best action. Record the patient’s answers to questions on the nursing assessment form. Ask an advanced practice nurse to perform the assessment interview. Call for a mental health advocate to maintain the patient’s rights. Obtain important information from the family member.
A nurse asks a patient, “If you had fever and vomiting for 3 days, what would you do?”
Which aspect of the mental status examination is the nurse assessing? Behavior Cognition Affect and mood perceptual disturbances.
An adolescent asks a nurse conducting an assessment interview, “Why should I tell you
anything? You’ll just tell my parents whatever you find out.” Which response by the nurse
is appropriate? “That isn’t true. What you tell us is private and held in strict confidence. Your
parents have no right to know.” “Yes, your parents may find out what you say, but it is important that they know
about your problems.” “What you say about feelings is private, but some things, like suicidal thinking,
must be reported to the treatment team.” “It sounds as though you are not really ready to work on your problems and make
changes.”.
A nurse wants to assess an adult patient’s recent memory. Which question would best yield
the desired information? “Where did you go to elementary school?” “What did you have for breakfast this morning?” “Can you name the current president of the United States?” “A few minutes ago, I told you my name. Can you remember it?”.
When a nurse assesses an older adult patient, answers seem vague or unrelated to the
questions. The patient also leans forward and frowns, listening intently to the nurse. An
appropriate question for the nurse to ask would be “Are you having difficulty hearing when I speak?” “How can I make this assessment interview easier for you?” “I notice you are frowning. Are you feeling annoyed with me?” “You’re having trouble focusing on what I’m saying. What is distracting you?”.
At what point in an assessment interview would a nurse ask, “How does your faith help you
in stressful situations?” During the assessment of childhood growth and development substance use and abuse educational background coping strategies.
When a new patient is hospitalized, a nurse takes the patient on a tour, explains rules of the
unit, and discusses the daily schedule. The nurse is engaged in counseling. health teaching. milieu management. psychobiological intervention.
After formulating the nursing diagnoses for a new patient, what is a nurse’s next action? Designing interventions to include in the plan of care Determining the goals and outcome criteria Implementing the nursing plan of care Completing the spiritual assessment.
Select the most appropriate label to complete this nursing diagnosis: ___________ related to
feelings of shyness and poorly developed social skills as evidenced by watching television
alone at home every evening. Deficient knowledge Ineffective coping Social isolation Powerlessness.
“QSEN” refers to Qualitative Standardized Excellence in Nursing. Quality and Safety Education for Nurses. Quantitative Effectiveness in Nursing. Quick Standards Essential for Nurses.
A nurse documents: “Patient is mute despite repeated efforts to elicit speech. Makes no eye
contact. Inattentive to staff. Gazes off to the side or looks upward rather than at speaker.”
Which nursing diagnosis should be considered? Defensive coping Decisional conflict Risk for other-directed violence Impaired verbal communication.
A nurse prepares to assess a new patient who moved to the United States from Central
America 3 years ago. After introductions, what is the nurse’s next comment? “How did you get to the United States?” “Would you like for a family member to help you talk with me?” “An interpreter is available. Would you like for me to make a request for these
services?” “Are you comfortable conversing in English, or would you prefer to have a
translator present?”.
The nurse records this entry in a patient’s progress notes:
Patient escorted to unit by ER nurse at 2130. Patient’s clothing was dirty. In interview
room, patient sat with hands over face, sobbing softly. Did not acknowledge nurse or reply
to questions. After several minutes, abruptly arose, ran to window, and pounded. Shouted
repeatedly, “Let me out of here.” Verbal intervention unsuccessful. Order for stat dose 2 mg
haloperidol PO obtained; medication administered at 2150. By 2215, patient stopped
shouting and returned to sit wordlessly in chair. Patient placed on one-to-one observation.
How should this documentation be evaluated? Uses unapproved abbreviations Contains subjective material Too brief to be of value Excessively wordy Meets standards.
A nurse assessed a patient who reluctantly participated in activities, answered questions
with minimal responses, and rarely made eye contact. What information should be included
when documenting the assessment? (Select all that apply.) The patient was uncooperative The patient’s subjective responses Only data obtained from the patient’s verbal responses A description of the patient’s behavior during the interview Analysis of why the patient was unresponsive during the interview.
A nurse performing an assessment interview for a patient with a substance use disorder
decides to use a standardized rating scale. Which scales are appropriate? (Select all that
apply.) Addiction Severity Index (ASI) Brief Drug Abuse Screen Test (B-DAST) Abnormal Involuntary Movement Scale (AIMS) Cognitive Capacity Screening Examination (CCSE) Recovery Attitude and Treatment Evaluator (RAATE).
What information is conveyed by nursing diagnoses? (Select all that apply.) Medical judgments about the disorder Unmet patient needs currently present Goals and outcomes for the plan of care Supporting data that validate the diagnoses Probable causes that will be targets for nursing interventions.
A patient is very suspicious and states, “The FBI has me under surveillance.” Which
strategies should a nurse use when gathering initial assessment data about this patient?
(Select all that apply.) Tell the patient that medication will help this type of thinking. Ask the patient, “Tell me about the problem as you see it.”
Seek information about when the problem began. Tell the patient, “Your ideas are not realistic.” Reassure the patient, “You are safe here.”.
A nurse assesses a confused older adult. The nurse experiences sadness and reflects, “This
patient is like one of my grandparents … so helpless.” Which response is the nurse
demonstrating? Transference Countertransference Catastrophic reaction Defensive coping reaction.
Which statement shows a nurse has empathy for a patient who made a suicide attempt? “You must have been very upset when you tried to hurt yourself.” “It makes me sad to see you going through such a difficult experience.” “If you tell me what is troubling you, I can help you solve your problems.” “Suicide is a drastic solution to a problem that may not be such a serious matter.”.
After several therapeutic encounters with a patient who recently attempted suicide, which
occurrence should cause the nurse to consider the possibility of countertransference? The patient’s reactions toward the nurse seem realistic and appropriate. The patient states, “Talking to you feels like talking to my parents.” The nurse feels unusually happy when the patient’s mood begins to lift. The nurse develops a trusting relationship with the patient.
A patient says, “Please don’t share information about me with the other people.” How
should the nurse respond? “I will not share information with your family or friends without your permission,
but I will share information about you with other staff.” “A therapeutic relationship is just between the nurse and the patient. It is up to you
to tell others what you want them to know.” “It depends on what you choose to tell me. I will be glad to disclose at the end of
each session what I will report to others.” “I cannot tell anyone about you. It will be as though I am talking about my own
problems, and we can help each other by keeping it between us.”.
A nurse is talking with a patient, and 5 minutes remain in the session. The patient has been
silent most of the session. Another patient comes to the door of the room, interrupts, and
says to the nurse, “I really need to talk to you.” The nurse should invite the interrupting patient to join in the session with the current patient. say to the interrupting patient, “I am not available to talk with you at the present
time.” end the unproductive session with the current patient and spend time with the
interrupting patient. tell the interrupting patient, “This session is 5 more minutes; then I will talk with
you.”.
Termination of a therapeutic nurse–patient relationship has been successful when the nurse avoids upsetting the patient by shifting focus to other patients before the discharge. gives the patient a personal telephone number and permission to call after
discharge. discusses with the patient changes that happened during the relationship and
evaluates outcomes. offers to meet the patient for coffee and conversation three times a week after
discharge.
What is the desirable outcome for the orientation stage of a nurse–patient relationship? The
patient will demonstrate behaviors that indicate self-responsibility and autonomy. a greater sense of independence. rapport and trust with the nurse. resolved transference.
During which phase of the nurse–patient relationship can the nurse anticipate that identified
patient issues will be explored and resolved? Preorientation Orientation Working Termination.
At what point in the nurse–patient relationship should a nurse plan to first address
termination? During the orientation phase At the end of the working phase Near the beginning of the termination phase When the patient initially brings up the topic.
A nurse introduces the matter of a contract during the first session with a new patient
because contracts specify what the nurse will do for the patient. spell out the participation and responsibilities of each party. indicate the feeling tone established between the participants. are binding and prevent either party from prematurely ending the relationship.
As a nurse escorts a patient being discharged after treatment for major depression, the
patient gives the nurse a necklace with a heart pendant and says, “Thank you for helping
mend my broken heart.” Which is the nurse’s best response? “Accepting gifts violates the policies and procedures of the facility.” “I’m glad you feel so much better now. Thank you for the beautiful necklace.” “I’m glad I could help you, but I can’t accept the gift. My reward is seeing you
with a renewed sense of hope.” “Helping people is what nursing is all about. It’s rewarding to me when patients
recognize how hard we work.”.
Which remark by a patient indicates passage from orientation to the working phase of a
nurse–patient relationship? “I don’t have any problems.” “It is so difficult for me to talk about problems.” “I don’t know how it will help to talk to you about my problems.” “I want to find a way to deal with my anger without becoming violent.”.
A nurse explains to the family of a mentally ill patient how a nurse–patient relationship
differs from social relationships. Which is the best explanation? “The focus is on the patient. Problems are discussed by the nurse and patient, but
solutions are implemented by the patient.” “The focus shifts from nurse to patient as the relationship develops. Advice is
given by both, and solutions are implemented.” “The focus of the relationship is socialization. Mutual needs are met, and feelings
are shared openly.” “The focus is creation of a partnership in which each member is concerned with
growth and satisfaction of the other.”.
A nurse wants to demonstrate genuineness with a patient diagnosed with schizophrenia. The
nurse should restate what the patient says. use congruent communication strategies. use self-revelation in patient interactions. consistently interpret the patient’s behaviors.
A nurse caring for a withdrawn, suspicious patient recognizes development of feelings of
anger toward the patient. The nurse should suppress the angry feelings. express the anger openly and directly with the patient. tell the nurse manager to assign the patient to another nurse discuss the anger with a clinician during a supervisory session.
A nurse wants to enhance growth of a patient by showing positive regard. The nurse’s action
most likely to achieve this goal is making rounds daily. staying with a tearful patient. administering medication as prescribed. examining personal feelings about a patient.
A patient says, “I’ve done a lot of cheating and manipulating in my relationships.” Select a
nonjudgmental response by the nurse. “How do you feel about that?” “I am glad that you realize this.” “That’s not a good way to behave.” “Have you outgrown that type of behavior?”.
A patient says, “People should be allowed to commit suicide without interference from
others.” A nurse replies, “You’re wrong. Nothing is bad enough to justify death.” What is
the best analysis of this interchange? The patient is correct. The nurse is correct. Neither person is correct. Differing values are reflected in the two statements.
Which issues should a nurse address during the first interview with a patient with a
psychiatric disorder? Trust, congruence, attitudes, and boundaries Goals, resistance, unconscious motivations, and diversion Relationship parameters, the contract, confidentiality, and termination Transference, countertransference, intimacy, and developing resources.
An advanced practice nurse observes a novice nurse expressing irritability regarding a
patient with a long history of alcoholism and suspects the new nurse is experiencing
countertransference. Which comment by the new nurse confirms this suspicion? “This patient continues to deny problems resulting from drinking.” “My parents were alcoholics and often neglected our family.” “The patient cannot identify any goals for improvement.” “The patient said I have many traits like her mother.”.
Which behavior shows that a nurse values autonomy? The nurse suggests one-on-one supervision for a patient who has suicidal thoughts. informs a patient that the spouse will not be in during visiting hours discusses options and helps the patient weigh the consequences. sets limits on a patient’s romantic overtures toward the nurse.
As a nurse discharges a patient, the patient gives the nurse a card of appreciation made in an
arts and crafts group. What is the nurse’s best action? Recognize the effectiveness of the relationship and patient’s thoughtfulness.
Accept the card. Inform the patient that accepting gifts violates policies of the facility. Decline the
card. Acknowledge the patient’s transition through the termination phase but decline the
card. Accept the card and invite the patient to return to participate in other arts and crafts
groups.
A patient says, “I’m still on restriction, but I want to attend some off-unit activities. Would
you ask the doctor to change my privileges?” What is the nurse’s best response? “Why are you asking me when you’re able to speak for yourself?” “I will be glad to address it when I see your doctor later today.” “That’s a good topic for you to discuss with your doctor.” “Do you think you can’t speak to a doctor?”.
A community mental health nurse has worked with a patient for 3 years but is moving out of
the city and terminates the relationship. When a novice nurse begins work with this patient,
what is the starting point for the relationship? Begin at the orientation phase. Resume the working relationship. Initially establish a social relationship. Return to the emotional catharsis phase.
As a patient diagnosed with a mental illness is being discharged from a facility, a nurse
invites the patient to the annual staff picnic. What is the best analysis of this scenario? The invitation facilitates dependency on the nurse. The nurse’s action blurs the boundaries of the therapeutic relationship. The invitation is therapeutic for the patient’s diversional activity deficit. The nurse’s action assists the patient’s integration into community living.
A nurse says, “I am the only one who truly understands this patient. Other staff members are
too critical.” The nurse’s statement indicates boundary blurring. sexual harassment. positive regard. advocacy.
Which comment best indicates that a patient perceived the nurse was caring? “My nurse always asks me which type of juice I want to help me swallow my medication.” explained my treatment plan to me and asked for my ideas about how to make it
better.” spends time listening to me talk about my problems. That helps me feel like I am
not alone.”
told me that if I take all the medicines the doctor prescribes, then I will get
discharged sooner.”.
A nurse ends a relationship with a patient. Which actions by the nurse should be included in
the termination phase? (Select all that apply.) Focus dialogues with the patient on problems that may occur in the future. Help the patient express feelings about the relationship with the nurse. Help the patient prioritize and modify socially unacceptable behaviors. Reinforce expectations regarding the parameters of the relationship. Help the patient to identify strengths, limitations, and problems.
A novice psychiatric nurse has a parent diagnosed with bipolar disorder. This nurse angrily
recalls feelings of embarrassment about the parent’s behavior in the community. Select the
best ways for this nurse to cope with these feelings. (Select all that apply.) Seek ways to use the understanding gained from childhood to help patients cope
with their own illnesses. Recognize that these feelings are unhealthy. The nurse should try to suppress them
when working with patients. Recognize that psychiatric nursing is not an appropriate career choice. Explore
other nursing specialties. The nurse should begin new patient relationships by saying, “My own parent had
mental illness, so I accept it without stigma.” Recognize that the feelings may add sensitivity to the nurse’s practice, but
supervision is important.
A novice nurse tells a mentor, “I want to convey to my patients that I am interested in them
and that I want to listen to what they have to say.” Which behaviors will be helpful in
meeting the nurse’s goal? (Select all that apply.) Sitting behind a desk, facing the patient Introducing self to a patient and identifying own role Maintaining control of discussions by asking direct questions Using facial expressions to convey interest and encouragement Assuming an open body posture and sometimes mirror imaging.
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