Chapter 5: Examination and Diagnosis of the Psychiatric Patient
MULTIPLE CHOICE
1. 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.
ANS: B
Prescriptive privileges are granted to masters-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.
2. 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
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.
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,3. 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.
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.
4. 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. c. sometimes demonstrated.
b. often demonstrated. d. never demonstrated.
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.
5. 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 nurses next
action?
a. Continue the current plan without changes.
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, 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.
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.
6. 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 c. Implementation
b. Analysis d. Evaluation
ANS: C
Interventions are the nursing prescriptions to achieve the outcomes. Interventions should be
specific.
MSC: Client Needs: Psychosocial Integrity
7. 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 isnt much improvement by the time of discharge.
The nurses responsibility is to:
a. document the other workers assessment of the patient.
b. assess the patient based on data collected from all sources.
c. validate the workers impression by contacting the patients significant other.
HTTPS://PASINGGRADES.COM/
MULTIPLE CHOICE
1. 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.
ANS: B
Prescriptive privileges are granted to masters-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.
2. 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
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.
HTTPS://PASINGGRADES.COM/
,3. 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.
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.
4. 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. c. sometimes demonstrated.
b. often demonstrated. d. never demonstrated.
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.
5. 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 nurses next
action?
a. Continue the current plan without changes.
HTTPS://PASINGGRADES.COM/
, 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.
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.
6. 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 c. Implementation
b. Analysis d. Evaluation
ANS: C
Interventions are the nursing prescriptions to achieve the outcomes. Interventions should be
specific.
MSC: Client Needs: Psychosocial Integrity
7. 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 isnt much improvement by the time of discharge.
The nurses responsibility is to:
a. document the other workers assessment of the patient.
b. assess the patient based on data collected from all sources.
c. validate the workers impression by contacting the patients significant other.
HTTPS://PASINGGRADES.COM/
