Varcarolis: Chapter 7 - The Nursing Process and Standards of
Care for Psychiatric Mental Health Nursing QUESTIONS WITH
WELL VERIFIED ANSWERS
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?
a. Perform mental health assessment interviews.
b. Prescribe psychotropic medication.
c. Establish therapeutic relationships.
d. Individualize nursing care plans. - answer☑️✔️..ANS: B
Prescriptive privileges are granted to master's-prepared nurse practitioners who have taken
special courses on prescribing medication. The nurse prepared at the basic level performs
mental health assessments, establishes relationships, and provides individualized care planning.
Note that this question was also offered for Chapter 1.
A newly admitted patient diagnosed with major depression has gained 20 pounds over a few
months and has suicidal ideation. The patient has taken an antidepressant medication for 1
week without remission of symptoms. Select the priority nursing diagnosis.
a. Imbalanced nutrition: more than body requirements
b. Chronic low self-esteem
c. Risk for suicide
d. Hopelessness - answer☑️✔️..ANS: C
Risk for suicide is the priority diagnosis when the patient has both suicidal ideation and a plan
to carry out the suicidal intent. Imbalanced nutrition, hopelessness, and chronic low self-esteem
may be applicable nursing diagnoses, but these problems do not affect patient safety as
urgently as would a suicide attempt.
A patient diagnosed with major depression has lost 20 pounds in one month, has chronic low
self-esteem, and a plan for suicide. The patient has taken an antidepressant medication for 1
week. Which nursing intervention has the highest priority?
,a. Implement suicide precautions.
b. Offer high-calorie snacks and fluids frequently.
c. Assist the patient to identify three personal strengths.
d. Observe patient for therapeutic effects of antidepressant medication. - answer☑️✔️..ANS: A
Implementing suicide precautions is the only option related to patient safety. The other options,
related to nutrition, self-esteem, and medication therapy, are important but are not priorities.
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:
a. consistently demonstrated.
b. often demonstrated.
c. sometimes demonstrated.
d. never demonstrated. - answer☑️✔️..ANS: D
Although the patient is sleeping 6 hours daily, the total is not one uninterrupted session at
night. Therefore, the outcome must be evaluated as never demonstrated. See relationship to
audience response question.
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?
a. Continue the current plan without changes.
b. Remove this nursing diagnosis from the plan of care.
c. Write a new nursing diagnosis that better reflects the problem.
d. Examine interventions for possible revision of the target date. - answer☑️✔️..ANS: D
Sleeping a total of 5 hours at night remains a reasonable outcome. Extending the period for
attaining the outcome may be appropriate. Examining interventions might result in planning an
, activity during the afternoon rather than permitting a nap. Continuing the current plan without
changes is inappropriate. Removing this nursing diagnosis from the plan of care would be
correct when the outcome was met and the problem resolved. Writing a new nursing diagnosis
is inappropriate because no other nursing diagnosis relates to the problem.
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"?
a. Assessment
b. Analysis
c. Implementation
d. Evaluation - answer☑️✔️..ANS: C
Interventions are the nursing prescriptions to achieve the outcomes. Interventions should be
specific.
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:
a. document the other worker's assessment of the patient.
b. assess the patient based on data collected from all sources.
c. validate the worker's impression by contacting the patient's significant other.
d. discuss the worker's impression with the patient during the assessment interview. -
answer☑️✔️..ANS: B
Assessment should include data obtained from both the primary and reliable secondary
sources. The nurse, bearing in mind the possible effects of counter-transference, should
evaluate biased assessments by others as objectively as possible.
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?
Care for Psychiatric Mental Health Nursing QUESTIONS WITH
WELL VERIFIED ANSWERS
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?
a. Perform mental health assessment interviews.
b. Prescribe psychotropic medication.
c. Establish therapeutic relationships.
d. Individualize nursing care plans. - answer☑️✔️..ANS: B
Prescriptive privileges are granted to master's-prepared nurse practitioners who have taken
special courses on prescribing medication. The nurse prepared at the basic level performs
mental health assessments, establishes relationships, and provides individualized care planning.
Note that this question was also offered for Chapter 1.
A newly admitted patient diagnosed with major depression has gained 20 pounds over a few
months and has suicidal ideation. The patient has taken an antidepressant medication for 1
week without remission of symptoms. Select the priority nursing diagnosis.
a. Imbalanced nutrition: more than body requirements
b. Chronic low self-esteem
c. Risk for suicide
d. Hopelessness - answer☑️✔️..ANS: C
Risk for suicide is the priority diagnosis when the patient has both suicidal ideation and a plan
to carry out the suicidal intent. Imbalanced nutrition, hopelessness, and chronic low self-esteem
may be applicable nursing diagnoses, but these problems do not affect patient safety as
urgently as would a suicide attempt.
A patient diagnosed with major depression has lost 20 pounds in one month, has chronic low
self-esteem, and a plan for suicide. The patient has taken an antidepressant medication for 1
week. Which nursing intervention has the highest priority?
,a. Implement suicide precautions.
b. Offer high-calorie snacks and fluids frequently.
c. Assist the patient to identify three personal strengths.
d. Observe patient for therapeutic effects of antidepressant medication. - answer☑️✔️..ANS: A
Implementing suicide precautions is the only option related to patient safety. The other options,
related to nutrition, self-esteem, and medication therapy, are important but are not priorities.
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:
a. consistently demonstrated.
b. often demonstrated.
c. sometimes demonstrated.
d. never demonstrated. - answer☑️✔️..ANS: D
Although the patient is sleeping 6 hours daily, the total is not one uninterrupted session at
night. Therefore, the outcome must be evaluated as never demonstrated. See relationship to
audience response question.
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?
a. Continue the current plan without changes.
b. Remove this nursing diagnosis from the plan of care.
c. Write a new nursing diagnosis that better reflects the problem.
d. Examine interventions for possible revision of the target date. - answer☑️✔️..ANS: D
Sleeping a total of 5 hours at night remains a reasonable outcome. Extending the period for
attaining the outcome may be appropriate. Examining interventions might result in planning an
, activity during the afternoon rather than permitting a nap. Continuing the current plan without
changes is inappropriate. Removing this nursing diagnosis from the plan of care would be
correct when the outcome was met and the problem resolved. Writing a new nursing diagnosis
is inappropriate because no other nursing diagnosis relates to the problem.
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"?
a. Assessment
b. Analysis
c. Implementation
d. Evaluation - answer☑️✔️..ANS: C
Interventions are the nursing prescriptions to achieve the outcomes. Interventions should be
specific.
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:
a. document the other worker's assessment of the patient.
b. assess the patient based on data collected from all sources.
c. validate the worker's impression by contacting the patient's significant other.
d. discuss the worker's impression with the patient during the assessment interview. -
answer☑️✔️..ANS: B
Assessment should include data obtained from both the primary and reliable secondary
sources. The nurse, bearing in mind the possible effects of counter-transference, should
evaluate biased assessments by others as objectively as possible.
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?
