Chapter 01: Me, Meds, Milieu
m m m m
Steele: Keltner’s Psychiatric Nursing, 9th Edition
m m m m m
MULTIPLEmCHOICE
1. Amnewlymlicensedmnursemasksmamnursingmrecruitermformamdescriptionmofmnursingmpracticeminm
thempsychiatricmsetting.mWhatm ismthemnursemrecruiter‘smbestmresponse?
a. ―Themnursemprimarilymservesminmamsupportivemrolemtommembersmofmthemhealthmcare
deliverym team.‖
b. ―Them multidisciplinarymapproachmeliminatesmthemneedmtom clearlymdefinemthe
responsibilitiesmofmnursingm inmsuchmamsetting.‖
c. ―Nursingmactionsmarem identifiedmbymthem institutionmthatm distinguishesmnursingm from
otherm mentalmhealthmprofessions.‖
d. ―Nursingmoffersmuniquemcontributionsmtomthempsychotherapeuticm managementmof
psychiatricm patients.‖
ANS:m D
Professionalmrolemoverlapmcannotmbemdenied;mhowever,mnursingmismuniqueminmitsmfocusmonmandm
applicationmofmpsychotherapeuticmmanagement.mNeithermthemfacilitymnormthemmultidisciplinarymt
eammdefinemthemprofessionalmresponsibilitiesmofmitsmmembersmbutmrathermutilizesmtheirmuniquems
killsmtomprovidemholisticmcare.mIdeally,mallmteammmembersmsupportmeachmothermandmhavemfuncti
onsmwithinmthemteam.
DIF: Cognitivemlevel:mAnalyzing
TOP:m Nursingmprocess:mImplementationmMSC:m ClientmNeeds:mSafe,mEffectiv
emCaremEnvironment
2. Whichmcomponentmofmthemnursingmprocessmwillmthemnursemfocusmuponmtomaddressmt
hemresponsibilitymtommatchmindividualmpatientm needsmwithmappropriatemservices?
a. Planning
b. Evaluation
c. Assessment
d. Implementation
ANS:m C
Propermassessmentmismcriticalmformbeingmablemtomdeterminemthemappropriatemlevelmofmservicesmth
atmwillmprovidemoptimalmcaremwhilemconsideringmpatientminputmandmatmthemlowestmcost.mPlanning
mandmimplementationmutilizesmthemassessmentmdatamtomidentifymandmexecutemactionsm(treatmentm
plan)mthatmwillmprovidemappropriatemcare.mEvaluationmvalidatesmthemeffectivenessmofmthemtreatme
ntmplan.
DIF: Cognitivemlevel:mApplying
TOP:m Nursingmprocess:mAssessmentmMSC:m ClientmNeeds:mSafe,mEffectiv
emCaremEnvironment
3. Anmadultmdiagnosedmwithmparanoidmschizophreniamfrequentlymexperiencesmauditorymhalluci
nationsmandmwalksmaboutmthemunit,mmuttering.mWhichmnursingmactionmdemonstratesmthemnurs
e‘smunderstandingmofmeffectivempsychotherapeuticm managementmofmthismclient?
a. Discussingmthemdiseasemprocessmofmschizophreniamwithmthemclientmandmtheirmdomestic
partner
b. Minimizingmcontactmbetweenmthismpatientmandmothermpatientsmtomassuremamstress-free
milieu
c. AdministeringmPRNmmedicationmwhenmfirstmobservingmthemevidencemthatmthemclient
, maymbemhallucinating
d. Independentlymdeterminingmthatmbehaviormmodificationmismappropriatemtomdecrease
themclient‘smparanoidmthoughts
ANS:m A
Anmunderstandingmofmpsychopathologymismthemfoundationmonmwhichmthemthreemcomponentsmofm
psychotherapeuticmmanagementmrest;mitmfacilitatesmtherapeuticmcommunicationmandmprovidesmam
basismformunderstandingmpsychopharmacologymandmmilieummanagement.mMinimizingmcontactm
betweenmthempatientmandmothersmandmadministeringmPRNmmedicationmindiscriminatelymaremnon
therapeuticminterventions.mUsingmbehaviormmodificationmtomdecreasemthemfrequencymofmhalluci
nationsmwouldmneedmtombemincorporatedmintomthemplanmofmcarembymthemcaremteam.
DIF: Cognitivemlevel:mApplying
TOP:m Nursingmprocess:mImplementationmMSC:m ClientmNeeds:mSafe,mEffectiv
emCaremEnvironment
4. Anmadultmdiagnosedmwithmchronicmdepressionmismhospitalizedmaftermamsuicidemattempt.mWhi
chminterventionmismcriticalminmassuringmlong-
term,meffectivemclientmcaremasmdescribedmbympsychotherapeuticmmanagement?
a. Involvementminmgroupmtherapies
b. Focusmofmclosemsupervisionmbymthemunitm staff
c. Maintainingmeffectivemcommunicationmwithmsupportmsystem
d. Frequentlymscheduledmone-on-onemtimemwithmnursingmstaff
ANS:m D
Amcriticalmelementmofmpsychotherapeuticmmanagementmismthempresencemofmamtherapeutic
nurse-patientmrelationship.mOne-on-
onemtimemwithmnursingmstaffmwillmhelpminmestablishingmthismconnection.mWhilemthemothermoptions
maremappropriatemandmclientmcentered,mthemnurse-clientmrelationmismcriticalminmthem long-
termmdeliverymofmqualitymeffectivemcaremtomthismclient.
DIF: Cognitivemlevel:mApplying
TOP:m Nursingmprocess:mImplementationmMSC:m ClientmNeeds:mPsychosocialmI
ntegrity
5. Ampatient‘smhaloperidolmdosagemwasmreducedm2mweeksmagomtomdecreasemsidemeffects.mWh
atmassessmentmquestionmdemonstratesmthemnurse‘smunderstandingmofmthemresultingmneedsmo
fmthemclient?
a. ―Willmyoumhavemanymdifficultymgettingm yourmprescriptionmrefilled?‖
b. ―Havem youmbegunmexperiencingmanymformsmofmhallucinations?‖
c. ―Whatm domyoumexpectmwillmoccurmsincemthemdosagemhasmbeenmreduced?‖
d. ―Whatm canmImdomtom helpm yoummanagemthismreductionminmhaloperidolmtherapy?‖
ANS:m B
Itmwillmbemnecessarymformthemnursemtomassessmformexacerbationmofmthempatient‘smsymptomsmofmp
sychosismasmwellmasmformamlesseningmofmsidemeffects.mDosagemdecreasemmightmleadmtomthemreturn
mormworseningmofmpositivemsymptomsmsuchmasmhallucinationsmandmdelusions,mandmnegativemsy
mptomsmsuchmasmbluntedmaffect,msocialmwithdrawal,mandmpoormgrooming.mWhilemthemothermopti
onsmmaymbemappropriatemassessmentmquestions,mtheymaremnotmdirectedmatmthemcurrentmneedsmofmt
hemclientm whichmismthemidentificationmofmemergingmpsychoticmbehaviors.
DIF: Cognitivemlevel:mAnalyzing
TOP:m Nursingmprocess:mAssessmentmMSC:m ClientmNeeds:mPhysiologicmIn
tegrity
,6. Whichmstatementmformsmthemfoundationmuponmwhichmamnursemshouldmbasemthemimplementation
mofmpsychotherapeuticmmanagementmtomthemcaremofmampatientm withmmentalmillness?
a. Themnurse‘smroleminmclientmcaremismsupportedmbymthemmultidisciplinarymteam.
b. Omittingmanymonemcomponentmwillmcompromisemthemeffectivenessmofmthemtreatment.
c. Themmostmimportantmelementmofmpsychotherapeuticmmanagementmismdrugmtherapy.
d. Amtherapeuticmnurse-patientmrelationshipmismthemmostmimportantmaspectmofmtreatment.
ANS:m B
Whenmonemelementmismmissing,mtreatmentmismusuallymcompromised.mNomsinglemelementmismmor
emimportantmthanmthemothers;mhowever,mpatients‘mneedsmgovernmthemapplicationmofmthemcompon
entsmandmpermitmjudiciousmuse.mThemremainingmoptionsmidentifymcomponentsmofmthempsychothe
rapeuticmmanagementm process.
DIF: Cognitivemlevel:mAnalyzing
TOP:m Nursingmprocess:mAnalysismMSC:m ClientmNeeds:mSafe,mEffectiv
emCaremEnvironment
7. Whichmstatementmmostmaccuratelymdescribesmamnurse‘smrolemregardingmpsychopharmacology?
a. ―YoumwillmneedmtomfrequentlymmakemdecisionsmregardingmthemadministrationmofmPRN
medicationsmtomhelpmthemclientm managemanger.‖
b. ―It‘smamnursingmresponsibilitymtom adjustm ammedicationmdosemtomassuremeffectivempatient
mresponses.‖
c. ―Nursesmadministersmmedicationsmwhilemevaluatingm drugmeffectivenessmismammedicalmr
esponsibility.‖
d. ―Tom bestm assuremappropriatemresponse,mampatient‘smquestionsmaboutm drugmtherapymsho
uldmbemreferredmtomthempsychiatrist.‖
ANS:m A
Nursingmassessmentm andmanalysismofmdatammightm suggestmthemneedmformPRNmmedicationmasmpat
ientmanxietymincreasesmormpsychoticmsymptomsmbecomemmoremacute.mThemnursemismthemhealthmt
eammmembermwhommakesmthismdetermination.mNursesmaremresponsiblemformmonitoringmdrugmeff
ectivenessmasmwellmasmadministeringmmedication.mNursesmshouldmassumemresponsibilitymformtea
chingmpatientsmaboutmthemsidemeffectsmofmmedications.mNursesmcannotmaltermprescribedmdosagesm
ofmmedicationsmunlessmtheymhavemprescriptivemprivileges.
DIF: Cognitivemlevel:mAnalyzing
TOP:m Nursingmprocess:mAnalysismMSC:m ClientmNeeds:mSafe,mEffectiv
emCaremEnvironment
8. Whenmconsideringmenvironmentalmaspectsmofmmilieummanagement,mwhichminterventionmhasmt
hemhighestmprioritymformamclientm admittedmaftermamfailedmsuicidemattempt?
a. Sendingmthemclient‘smnewmmedicationmprescriptionsmtomthempharmacy
b. Assigningmamstaffmmembermtomone-on-onemobservationmofmthemclient
c. Orientingmthemclientmtomthemmilieu‘smpublicmandmprivatemspaces
d. Havingmallmpotentiallymdangerousmitemsmremovedmfrommthemclient‘smbelongings
ANS:m B
Milieummanagementmprovidesmamproactivemapproachmtomcare.mSafetymoverridesmallmothermdime
nsionsmofmthemmilieu.mInitiationmofmsuicidemprecautionsmaremthemprioritymformthismclient.mAllmthem
remainingmoptionsmaremappropriatembutmnonemprotectmthemclientmfrommthemriskmofmanothermatte
mptmtomself-harmmasmeffectivelymasmone-on-onemobservationmasmpartmofmsuicidemprecautions.
DIF: Cognitivemlevel:mAnalyzing TOP:m Nursingmprocess:mImplementation
, MSC:m ClientmNeeds:mSafe,mEffectivemCaremEnvironment
9. Themimplementationmofmwhichmunitmpolicymdirectedmatmmilieumbalancemwouldmreflectmamneedm
formreconsiderationmonmthempartmofmthemtreatmentmteam?
a. Allmclientsmwillmreceivemverbalmandmwrittenminformationmexplainingmunitmrules.
b. Unitmclientsmwillmengageminmallmunitmactivitiesmtomassureminteractionmwithmbothmstaf
fmandmothermclients.
c. Allmclientsmwillmbemuniformlymexpectedmtompresentmthemselvesminmamnonviolentmma
nnermtom bothmstaffmandmothermclients.
d. Atmtimesmofmunitmstress,mclientmwillmreturnmtomtheirmrooms.
ANS:m B
Themsituationmdescribedmsuggestsmammilieuminmwhichmpatientsmhavemnomtimemformplannedmtherap
euticmencountersmwithmstaff;mhence,mitmismammilieumlackingmbalance.mThemremainingmoptionsmadd
ressmunitmnorms,mlimitmsetting,mandmenvironmentalmmodificationsmthatmaremreasonablemandmwillmc
ontributemtom amtherapeuticm milieu.
DIF: Cognitivemlevel:mEvaluating
TOP:m Nursingmprocess:mEvaluationmMSC:m ClientmNeeds:mSafe,mEffectiv
emCaremEnvironment
10. Whichminterventionmshouldmthemnursemimplementmwhenmfocusingmonmcommunicati
ngmtherapeuticallymwithmamclient?
a. Explainingmtomthemclientmwhymtheymwillmneedmtomaskmformamrazor
b. Providingmthemclientmwithmoptionsmtomhelpmachievemsmokingmcessation
c. Encouragingmthemclientmtomidentifympersonalmstressors
d. Assuringmthemclientmthatmtheymcanmreceivemtelephonemcallmonmthemunitmtelephone
ANS:m C
Amnursemusesmtherapeuticmcommunicationmtechniquesmasmpartmofmthemtherapeuticmnurse-
patientmrelationship.mAnmexamplemofmsuchmcommunicationmismprovidingmthemclientm withmanmopp
ortunitymtomsafelymidentifympersonalmstressors.mThemremainingmoptionsmaddressmsafety,mbalance,m
andmnormsmassociatedmwithmtheirmcare.
DIF: Cognitivemlevel:mApplying
TOP:m Nursingmprocess:mImplementationmMSC:m ClientmNeeds:mPsychosocialmI
ntegrity
11. Duringmthemriskmassessmentmphasemofmcaremformampsychiatricmpatient,mwhatmismthemnurse‘smprim
arymgoal?
a. Makingmanminitialmassessment
b. Confirmingmthempatient‘smproblem
c. Assessingmpotentialmdangerousnessmtomselfmormothers
d. Determiningmthemlevelmofmsupervisionmneededmformthempatient
ANS:m C
Riskmassessmentminvolvesmlookingmatmdangerousnessmtomselfmormothers,mthemdegreemofmdisabilit
y,mandmwhethermormnotmthemindividualmismacutelympsychoticmtomdeterminemthemfeasibilitymofmco
mmunity-basedmcaremversusmhospital-
basedmcare.mRiskmassessmentmusuallymfollowsmtheminitialmassessment.mConfirmationmofmthempati
ent‘smproblemmismnotmpartmofmthemriskmassessmentmprotocol.mArrangingmentrymintomthemmentalmh
ealthmsystemmwillmfollowmriskmassessmentmifmthempatientmismassessedmasmneedingmservice.
DIF: Cognitivemlevel:mApplying TOP:m Nursingmprocess:mAssessment
m m m m
Steele: Keltner’s Psychiatric Nursing, 9th Edition
m m m m m
MULTIPLEmCHOICE
1. Amnewlymlicensedmnursemasksmamnursingmrecruitermformamdescriptionmofmnursingmpracticeminm
thempsychiatricmsetting.mWhatm ismthemnursemrecruiter‘smbestmresponse?
a. ―Themnursemprimarilymservesminmamsupportivemrolemtommembersmofmthemhealthmcare
deliverym team.‖
b. ―Them multidisciplinarymapproachmeliminatesmthemneedmtom clearlymdefinemthe
responsibilitiesmofmnursingm inmsuchmamsetting.‖
c. ―Nursingmactionsmarem identifiedmbymthem institutionmthatm distinguishesmnursingm from
otherm mentalmhealthmprofessions.‖
d. ―Nursingmoffersmuniquemcontributionsmtomthempsychotherapeuticm managementmof
psychiatricm patients.‖
ANS:m D
Professionalmrolemoverlapmcannotmbemdenied;mhowever,mnursingmismuniqueminmitsmfocusmonmandm
applicationmofmpsychotherapeuticmmanagement.mNeithermthemfacilitymnormthemmultidisciplinarymt
eammdefinemthemprofessionalmresponsibilitiesmofmitsmmembersmbutmrathermutilizesmtheirmuniquems
killsmtomprovidemholisticmcare.mIdeally,mallmteammmembersmsupportmeachmothermandmhavemfuncti
onsmwithinmthemteam.
DIF: Cognitivemlevel:mAnalyzing
TOP:m Nursingmprocess:mImplementationmMSC:m ClientmNeeds:mSafe,mEffectiv
emCaremEnvironment
2. Whichmcomponentmofmthemnursingmprocessmwillmthemnursemfocusmuponmtomaddressmt
hemresponsibilitymtommatchmindividualmpatientm needsmwithmappropriatemservices?
a. Planning
b. Evaluation
c. Assessment
d. Implementation
ANS:m C
Propermassessmentmismcriticalmformbeingmablemtomdeterminemthemappropriatemlevelmofmservicesmth
atmwillmprovidemoptimalmcaremwhilemconsideringmpatientminputmandmatmthemlowestmcost.mPlanning
mandmimplementationmutilizesmthemassessmentmdatamtomidentifymandmexecutemactionsm(treatmentm
plan)mthatmwillmprovidemappropriatemcare.mEvaluationmvalidatesmthemeffectivenessmofmthemtreatme
ntmplan.
DIF: Cognitivemlevel:mApplying
TOP:m Nursingmprocess:mAssessmentmMSC:m ClientmNeeds:mSafe,mEffectiv
emCaremEnvironment
3. Anmadultmdiagnosedmwithmparanoidmschizophreniamfrequentlymexperiencesmauditorymhalluci
nationsmandmwalksmaboutmthemunit,mmuttering.mWhichmnursingmactionmdemonstratesmthemnurs
e‘smunderstandingmofmeffectivempsychotherapeuticm managementmofmthismclient?
a. Discussingmthemdiseasemprocessmofmschizophreniamwithmthemclientmandmtheirmdomestic
partner
b. Minimizingmcontactmbetweenmthismpatientmandmothermpatientsmtomassuremamstress-free
milieu
c. AdministeringmPRNmmedicationmwhenmfirstmobservingmthemevidencemthatmthemclient
, maymbemhallucinating
d. Independentlymdeterminingmthatmbehaviormmodificationmismappropriatemtomdecrease
themclient‘smparanoidmthoughts
ANS:m A
Anmunderstandingmofmpsychopathologymismthemfoundationmonmwhichmthemthreemcomponentsmofm
psychotherapeuticmmanagementmrest;mitmfacilitatesmtherapeuticmcommunicationmandmprovidesmam
basismformunderstandingmpsychopharmacologymandmmilieummanagement.mMinimizingmcontactm
betweenmthempatientmandmothersmandmadministeringmPRNmmedicationmindiscriminatelymaremnon
therapeuticminterventions.mUsingmbehaviormmodificationmtomdecreasemthemfrequencymofmhalluci
nationsmwouldmneedmtombemincorporatedmintomthemplanmofmcarembymthemcaremteam.
DIF: Cognitivemlevel:mApplying
TOP:m Nursingmprocess:mImplementationmMSC:m ClientmNeeds:mSafe,mEffectiv
emCaremEnvironment
4. Anmadultmdiagnosedmwithmchronicmdepressionmismhospitalizedmaftermamsuicidemattempt.mWhi
chminterventionmismcriticalminmassuringmlong-
term,meffectivemclientmcaremasmdescribedmbympsychotherapeuticmmanagement?
a. Involvementminmgroupmtherapies
b. Focusmofmclosemsupervisionmbymthemunitm staff
c. Maintainingmeffectivemcommunicationmwithmsupportmsystem
d. Frequentlymscheduledmone-on-onemtimemwithmnursingmstaff
ANS:m D
Amcriticalmelementmofmpsychotherapeuticmmanagementmismthempresencemofmamtherapeutic
nurse-patientmrelationship.mOne-on-
onemtimemwithmnursingmstaffmwillmhelpminmestablishingmthismconnection.mWhilemthemothermoptions
maremappropriatemandmclientmcentered,mthemnurse-clientmrelationmismcriticalminmthem long-
termmdeliverymofmqualitymeffectivemcaremtomthismclient.
DIF: Cognitivemlevel:mApplying
TOP:m Nursingmprocess:mImplementationmMSC:m ClientmNeeds:mPsychosocialmI
ntegrity
5. Ampatient‘smhaloperidolmdosagemwasmreducedm2mweeksmagomtomdecreasemsidemeffects.mWh
atmassessmentmquestionmdemonstratesmthemnurse‘smunderstandingmofmthemresultingmneedsmo
fmthemclient?
a. ―Willmyoumhavemanymdifficultymgettingm yourmprescriptionmrefilled?‖
b. ―Havem youmbegunmexperiencingmanymformsmofmhallucinations?‖
c. ―Whatm domyoumexpectmwillmoccurmsincemthemdosagemhasmbeenmreduced?‖
d. ―Whatm canmImdomtom helpm yoummanagemthismreductionminmhaloperidolmtherapy?‖
ANS:m B
Itmwillmbemnecessarymformthemnursemtomassessmformexacerbationmofmthempatient‘smsymptomsmofmp
sychosismasmwellmasmformamlesseningmofmsidemeffects.mDosagemdecreasemmightmleadmtomthemreturn
mormworseningmofmpositivemsymptomsmsuchmasmhallucinationsmandmdelusions,mandmnegativemsy
mptomsmsuchmasmbluntedmaffect,msocialmwithdrawal,mandmpoormgrooming.mWhilemthemothermopti
onsmmaymbemappropriatemassessmentmquestions,mtheymaremnotmdirectedmatmthemcurrentmneedsmofmt
hemclientm whichmismthemidentificationmofmemergingmpsychoticmbehaviors.
DIF: Cognitivemlevel:mAnalyzing
TOP:m Nursingmprocess:mAssessmentmMSC:m ClientmNeeds:mPhysiologicmIn
tegrity
,6. Whichmstatementmformsmthemfoundationmuponmwhichmamnursemshouldmbasemthemimplementation
mofmpsychotherapeuticmmanagementmtomthemcaremofmampatientm withmmentalmillness?
a. Themnurse‘smroleminmclientmcaremismsupportedmbymthemmultidisciplinarymteam.
b. Omittingmanymonemcomponentmwillmcompromisemthemeffectivenessmofmthemtreatment.
c. Themmostmimportantmelementmofmpsychotherapeuticmmanagementmismdrugmtherapy.
d. Amtherapeuticmnurse-patientmrelationshipmismthemmostmimportantmaspectmofmtreatment.
ANS:m B
Whenmonemelementmismmissing,mtreatmentmismusuallymcompromised.mNomsinglemelementmismmor
emimportantmthanmthemothers;mhowever,mpatients‘mneedsmgovernmthemapplicationmofmthemcompon
entsmandmpermitmjudiciousmuse.mThemremainingmoptionsmidentifymcomponentsmofmthempsychothe
rapeuticmmanagementm process.
DIF: Cognitivemlevel:mAnalyzing
TOP:m Nursingmprocess:mAnalysismMSC:m ClientmNeeds:mSafe,mEffectiv
emCaremEnvironment
7. Whichmstatementmmostmaccuratelymdescribesmamnurse‘smrolemregardingmpsychopharmacology?
a. ―YoumwillmneedmtomfrequentlymmakemdecisionsmregardingmthemadministrationmofmPRN
medicationsmtomhelpmthemclientm managemanger.‖
b. ―It‘smamnursingmresponsibilitymtom adjustm ammedicationmdosemtomassuremeffectivempatient
mresponses.‖
c. ―Nursesmadministersmmedicationsmwhilemevaluatingm drugmeffectivenessmismammedicalmr
esponsibility.‖
d. ―Tom bestm assuremappropriatemresponse,mampatient‘smquestionsmaboutm drugmtherapymsho
uldmbemreferredmtomthempsychiatrist.‖
ANS:m A
Nursingmassessmentm andmanalysismofmdatammightm suggestmthemneedmformPRNmmedicationmasmpat
ientmanxietymincreasesmormpsychoticmsymptomsmbecomemmoremacute.mThemnursemismthemhealthmt
eammmembermwhommakesmthismdetermination.mNursesmaremresponsiblemformmonitoringmdrugmeff
ectivenessmasmwellmasmadministeringmmedication.mNursesmshouldmassumemresponsibilitymformtea
chingmpatientsmaboutmthemsidemeffectsmofmmedications.mNursesmcannotmaltermprescribedmdosagesm
ofmmedicationsmunlessmtheymhavemprescriptivemprivileges.
DIF: Cognitivemlevel:mAnalyzing
TOP:m Nursingmprocess:mAnalysismMSC:m ClientmNeeds:mSafe,mEffectiv
emCaremEnvironment
8. Whenmconsideringmenvironmentalmaspectsmofmmilieummanagement,mwhichminterventionmhasmt
hemhighestmprioritymformamclientm admittedmaftermamfailedmsuicidemattempt?
a. Sendingmthemclient‘smnewmmedicationmprescriptionsmtomthempharmacy
b. Assigningmamstaffmmembermtomone-on-onemobservationmofmthemclient
c. Orientingmthemclientmtomthemmilieu‘smpublicmandmprivatemspaces
d. Havingmallmpotentiallymdangerousmitemsmremovedmfrommthemclient‘smbelongings
ANS:m B
Milieummanagementmprovidesmamproactivemapproachmtomcare.mSafetymoverridesmallmothermdime
nsionsmofmthemmilieu.mInitiationmofmsuicidemprecautionsmaremthemprioritymformthismclient.mAllmthem
remainingmoptionsmaremappropriatembutmnonemprotectmthemclientmfrommthemriskmofmanothermatte
mptmtomself-harmmasmeffectivelymasmone-on-onemobservationmasmpartmofmsuicidemprecautions.
DIF: Cognitivemlevel:mAnalyzing TOP:m Nursingmprocess:mImplementation
, MSC:m ClientmNeeds:mSafe,mEffectivemCaremEnvironment
9. Themimplementationmofmwhichmunitmpolicymdirectedmatmmilieumbalancemwouldmreflectmamneedm
formreconsiderationmonmthempartmofmthemtreatmentmteam?
a. Allmclientsmwillmreceivemverbalmandmwrittenminformationmexplainingmunitmrules.
b. Unitmclientsmwillmengageminmallmunitmactivitiesmtomassureminteractionmwithmbothmstaf
fmandmothermclients.
c. Allmclientsmwillmbemuniformlymexpectedmtompresentmthemselvesminmamnonviolentmma
nnermtom bothmstaffmandmothermclients.
d. Atmtimesmofmunitmstress,mclientmwillmreturnmtomtheirmrooms.
ANS:m B
Themsituationmdescribedmsuggestsmammilieuminmwhichmpatientsmhavemnomtimemformplannedmtherap
euticmencountersmwithmstaff;mhence,mitmismammilieumlackingmbalance.mThemremainingmoptionsmadd
ressmunitmnorms,mlimitmsetting,mandmenvironmentalmmodificationsmthatmaremreasonablemandmwillmc
ontributemtom amtherapeuticm milieu.
DIF: Cognitivemlevel:mEvaluating
TOP:m Nursingmprocess:mEvaluationmMSC:m ClientmNeeds:mSafe,mEffectiv
emCaremEnvironment
10. Whichminterventionmshouldmthemnursemimplementmwhenmfocusingmonmcommunicati
ngmtherapeuticallymwithmamclient?
a. Explainingmtomthemclientmwhymtheymwillmneedmtomaskmformamrazor
b. Providingmthemclientmwithmoptionsmtomhelpmachievemsmokingmcessation
c. Encouragingmthemclientmtomidentifympersonalmstressors
d. Assuringmthemclientmthatmtheymcanmreceivemtelephonemcallmonmthemunitmtelephone
ANS:m C
Amnursemusesmtherapeuticmcommunicationmtechniquesmasmpartmofmthemtherapeuticmnurse-
patientmrelationship.mAnmexamplemofmsuchmcommunicationmismprovidingmthemclientm withmanmopp
ortunitymtomsafelymidentifympersonalmstressors.mThemremainingmoptionsmaddressmsafety,mbalance,m
andmnormsmassociatedmwithmtheirmcare.
DIF: Cognitivemlevel:mApplying
TOP:m Nursingmprocess:mImplementationmMSC:m ClientmNeeds:mPsychosocialmI
ntegrity
11. Duringmthemriskmassessmentmphasemofmcaremformampsychiatricmpatient,mwhatmismthemnurse‘smprim
arymgoal?
a. Makingmanminitialmassessment
b. Confirmingmthempatient‘smproblem
c. Assessingmpotentialmdangerousnessmtomselfmormothers
d. Determiningmthemlevelmofmsupervisionmneededmformthempatient
ANS:m C
Riskmassessmentminvolvesmlookingmatmdangerousnessmtomselfmormothers,mthemdegreemofmdisabilit
y,mandmwhethermormnotmthemindividualmismacutelympsychoticmtomdeterminemthemfeasibilitymofmco
mmunity-basedmcaremversusmhospital-
basedmcare.mRiskmassessmentmusuallymfollowsmtheminitialmassessment.mConfirmationmofmthempati
ent‘smproblemmismnotmpartmofmthemriskmassessmentmprotocol.mArrangingmentrymintomthemmentalmh
ealthmsystemmwillmfollowmriskmassessmentmifmthempatientmismassessedmasmneedingmservice.
DIF: Cognitivemlevel:mApplying TOP:m Nursingmprocess:mAssessment
