Chapter 9. The Nursing Process in
Psychiatric/Mental Health Nursing
A client diagnosed with major depressive disorder states, "Why should I keep trying to get a
job? I mess up everything I do." Which correctly written nursing diagnosis best reflects the
content and mood themes in this client's statement?
A. Hopelessness R/T poor job performance
B. Risk for impaired adjustment R/T inadequate social skills AEB isolation
C. Altered role performance R/T the fear of failure AEB not seeking employment
D. Chronic low self-esteem R/T major depressive disorder AEB self-hatred - ANS-ANS: C
An actual nursing diagnosis must include related to (R/T) and as evidenced by (AEB)
statements. A "risk for" diagnosis does not contain AEB because there is only a potential for the
problem; it doesn't yet exist. The client's statement indicates that role performance is altered
because fear of failure prevents seeking employment.
KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis | Client Need:
Psychosocial Integrity
\A client diagnosed with schizophrenia is exhibiting nonverbal behaviors indicating that the client
is hearing things that others do not. Which nursing diagnosis accurately reflects this client's
problem?
A. Altered thought processes
B. Altered sensory perception
C. Anxiety
D. Chronic confusion - ANS-ANS: B
The nursing diagnosis altered sensory perception accurately reflects the client's symptoms of
hearing things that others do not. A nursing diagnosis describes a client's condition and
facilitates the prescription of interventions. Delusional thinking, confusion, and disorientation are
problems associated with the nursing diagnosis of altered thought processes.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Analysis | Client
Need: Psychosocial Integrity
\A client has a nursing diagnosis of Insomnia R/T paranoid thinking AEB midnight awakenings,
difficulty falling asleep, and daytime napping. Which is a correctly written and appropriate
outcome for this client's problem?
A. The client will avoid daytime napping and attend all groups.
B. The client will exercise, as needed, before bedtime.
C. The client will sleep 7 uninterrupted hours by day four of hospitalization.
D. The client's sleep habits will improve during hospitalization. - ANS-ANS: C
The outcome "The client will sleep 7 uninterrupted hours by day four of hospitalization" is
accurately written and an appropriate outcome to address the client problem of insomnia.
, Outcomes should be measurable, realistic, client-focused goals that include a time frame.
Appropriate nursing interventions are guided by client outcomes.
KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Planning | Client Need:
Psychosocial Integrity
\A client is assigned the nursing diagnosis of impaired social interaction R/T sociocultural
differences AEB client stating, "Although I'd like to, I don't join in because I don't speak the
language so good." Which correctly written outcome addresses this client's problem?
A. The client will collaborate with nursing staff to set specific goals by day 3.
B. The client will participate in one group activity of choice by day 2.
C. The client will express a desire to interact with others.
D. The client will become increasingly independent by discharge. - ANS-ANS: B
In the planning phase of the nursing process, the nurse works with the client to identify expected
outcomes for a plan individualized to the client need or to the situation.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client
Need: Psychosocial Integrity
\A client is diagnosed with generalized anxiety disorder. In order to maximize the learning
process prior to discharge teaching, which assessment should be performed by the nurse?
A. Assessing the client's level of anxiety
B. Assessing and documenting the client's vital signs
C. Assessing suicide risk
D. Assessing availability of support systems - ANS-ANS: A
Anxiety at a moderate or higher level will interfere with the learning process.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client
Need: Psychosocial Integrity
\A client who has slept 6 hours the previous night reports this to the assigned psychiatric nurse.
What should be the initial nursing action to address this situation?
A. Provide warm milk and a backrub.
B. Give a sleep medication.
C. Hold a relaxation group before bedtime.
D. Review the client's normal sleep pattern. - ANS-ANS: D
In the assessment phase of the nursing process, the nurse collects comprehensive health data
that are pertinent to the client's health or situation. In this situation the nurse must initially
determine the client's normal sleep patterns in order to evaluate if a true problem exists.
KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client
Need: Safe and Effective Care Environment
\A nurse charts "Verbalizes understanding of the side effects of Prozac." This is an example of
which category of focused charting?
A. Data
B. Problem
C. Action
Psychiatric/Mental Health Nursing
A client diagnosed with major depressive disorder states, "Why should I keep trying to get a
job? I mess up everything I do." Which correctly written nursing diagnosis best reflects the
content and mood themes in this client's statement?
A. Hopelessness R/T poor job performance
B. Risk for impaired adjustment R/T inadequate social skills AEB isolation
C. Altered role performance R/T the fear of failure AEB not seeking employment
D. Chronic low self-esteem R/T major depressive disorder AEB self-hatred - ANS-ANS: C
An actual nursing diagnosis must include related to (R/T) and as evidenced by (AEB)
statements. A "risk for" diagnosis does not contain AEB because there is only a potential for the
problem; it doesn't yet exist. The client's statement indicates that role performance is altered
because fear of failure prevents seeking employment.
KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis | Client Need:
Psychosocial Integrity
\A client diagnosed with schizophrenia is exhibiting nonverbal behaviors indicating that the client
is hearing things that others do not. Which nursing diagnosis accurately reflects this client's
problem?
A. Altered thought processes
B. Altered sensory perception
C. Anxiety
D. Chronic confusion - ANS-ANS: B
The nursing diagnosis altered sensory perception accurately reflects the client's symptoms of
hearing things that others do not. A nursing diagnosis describes a client's condition and
facilitates the prescription of interventions. Delusional thinking, confusion, and disorientation are
problems associated with the nursing diagnosis of altered thought processes.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Analysis | Client
Need: Psychosocial Integrity
\A client has a nursing diagnosis of Insomnia R/T paranoid thinking AEB midnight awakenings,
difficulty falling asleep, and daytime napping. Which is a correctly written and appropriate
outcome for this client's problem?
A. The client will avoid daytime napping and attend all groups.
B. The client will exercise, as needed, before bedtime.
C. The client will sleep 7 uninterrupted hours by day four of hospitalization.
D. The client's sleep habits will improve during hospitalization. - ANS-ANS: C
The outcome "The client will sleep 7 uninterrupted hours by day four of hospitalization" is
accurately written and an appropriate outcome to address the client problem of insomnia.
, Outcomes should be measurable, realistic, client-focused goals that include a time frame.
Appropriate nursing interventions are guided by client outcomes.
KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Planning | Client Need:
Psychosocial Integrity
\A client is assigned the nursing diagnosis of impaired social interaction R/T sociocultural
differences AEB client stating, "Although I'd like to, I don't join in because I don't speak the
language so good." Which correctly written outcome addresses this client's problem?
A. The client will collaborate with nursing staff to set specific goals by day 3.
B. The client will participate in one group activity of choice by day 2.
C. The client will express a desire to interact with others.
D. The client will become increasingly independent by discharge. - ANS-ANS: B
In the planning phase of the nursing process, the nurse works with the client to identify expected
outcomes for a plan individualized to the client need or to the situation.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client
Need: Psychosocial Integrity
\A client is diagnosed with generalized anxiety disorder. In order to maximize the learning
process prior to discharge teaching, which assessment should be performed by the nurse?
A. Assessing the client's level of anxiety
B. Assessing and documenting the client's vital signs
C. Assessing suicide risk
D. Assessing availability of support systems - ANS-ANS: A
Anxiety at a moderate or higher level will interfere with the learning process.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client
Need: Psychosocial Integrity
\A client who has slept 6 hours the previous night reports this to the assigned psychiatric nurse.
What should be the initial nursing action to address this situation?
A. Provide warm milk and a backrub.
B. Give a sleep medication.
C. Hold a relaxation group before bedtime.
D. Review the client's normal sleep pattern. - ANS-ANS: D
In the assessment phase of the nursing process, the nurse collects comprehensive health data
that are pertinent to the client's health or situation. In this situation the nurse must initially
determine the client's normal sleep patterns in order to evaluate if a true problem exists.
KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client
Need: Safe and Effective Care Environment
\A nurse charts "Verbalizes understanding of the side effects of Prozac." This is an example of
which category of focused charting?
A. Data
B. Problem
C. Action
