C HAPTER 07: T HE N URSING P ROCESS AND
S TANDARDS OF C ARE
Varcarolis’ Foundations of Psychiatric -Mental Health Nursing: 8th Edition
MULTIPLE CHOICE
1. Which entry in the medica l record best meets the requirement for problem -
oriented charting?
a. A: Pacing and muttering to self. P: Sensory perceptual alteration
related to internal auditory stimulation. I: Given fluphenazine HCL
(Prolixin) 2.5 mg po at 0900 and went to room to lie do wn. E:
Calmer by 0930. Returned to lounge to watch TV.
b. S: States, I feel like Im ready to blow up. O: Pacing hall, mumbling
to self. A: Auditory hallucinations. P: Offer haloperidol (Haldol) 2
mg po. I: Haloperidol (Haldol) 2 mg po given at 0900. E: Return ed
to lounge at 0930 and quietl y watched TV.
c. Agitated behavior. D: Patient muttering to self as though answering
an unseen person. A: Given haloperidol (Haldol) 2 mg po and went
to room to lie down. E: Patient calmer. Returned to lounge to watch
TV.
d. Pacing hall and muttering to self as though answering an unseen
person. haloperidol (Haldol) 2 mg po administered at 0900 with
calming effect in 30 minutes. Stated, Im no longer bothered by the
voices.
ANS: B
, Problem-oriented documentation uses the first lette r of key words to
organize data: S for subjective data, O for objective data, A for
assessment, P for plan, I for intervention, and E for evaluation. The
distracters offer examples of P IE charting, focus documentation, and
narrative documentation.
PTS: 1 DIF: Cognitive Level: Anal yze (Anal ysis) REF: 120
TOP: Nursing Process: Implementation MSC: Client
Needs: Safe, Effective Care Environment
2. A nurse assesses an older adult patient brought to the emergency
department by a family member. The patient was wandering outside
saying, I cant find my way home. The patient is confused and unable to
answer questions. Select the nurses best action.
a. Record the patients answers to questions on the nursing assessment
form.
b. Ask an advanced practice nurse to perform the assessment
interview.
c. Call for a mental health advocate to maintain the patients rights.
d. Obtain important information from the famil y member.
ANS: D
When the patient (primary source) is unable to provide information,
secondary sources should be used, in this case, the famil y member.
Later, more data may be obtained from other information sources
familiar with the patient. An advanced practice nurse is not needed for
this assessment; it is within the scope of practice of the staff nurse.
Calling a mental health advocate is unnecessary. See relationship to
audience response question.
, PTS: 1 DIF: Cognitive Level: Appl y (Application)
REF: 111 TOP: Nursing Process: Assessment MSC:
Client Needs: Safe, Effective Care Environment
3. 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?
a. Behavior
b. Cognition
c. Affect and mood
d. Perceptual disturbances
ANS: B
Assessing cognition involves determining a patients judg ment and
decision making. In this case, the nurse would expect a response of
Call m y doctor if the patients cognition and judgment are intact. If the
patient responds, I would stop eating or I would just wait and see what
happened, the nurse would conclude that judgment is impaired. The
other options refer to other aspects of the examination.
PTS: 1 DIF: Cognitive Level: Appl y (Application)
REF: 114 TOP: Nursing Process: Assessment MSC:
Client Needs: Psychosocial Integrit y
4. An adolescent asks a nurse c onducting an assessment interview, Why
should I tell you anything? Youll just tell m y parents whatever you find
out. Which response by the nurse is appropriate?
S TANDARDS OF C ARE
Varcarolis’ Foundations of Psychiatric -Mental Health Nursing: 8th Edition
MULTIPLE CHOICE
1. Which entry in the medica l record best meets the requirement for problem -
oriented charting?
a. A: Pacing and muttering to self. P: Sensory perceptual alteration
related to internal auditory stimulation. I: Given fluphenazine HCL
(Prolixin) 2.5 mg po at 0900 and went to room to lie do wn. E:
Calmer by 0930. Returned to lounge to watch TV.
b. S: States, I feel like Im ready to blow up. O: Pacing hall, mumbling
to self. A: Auditory hallucinations. P: Offer haloperidol (Haldol) 2
mg po. I: Haloperidol (Haldol) 2 mg po given at 0900. E: Return ed
to lounge at 0930 and quietl y watched TV.
c. Agitated behavior. D: Patient muttering to self as though answering
an unseen person. A: Given haloperidol (Haldol) 2 mg po and went
to room to lie down. E: Patient calmer. Returned to lounge to watch
TV.
d. Pacing hall and muttering to self as though answering an unseen
person. haloperidol (Haldol) 2 mg po administered at 0900 with
calming effect in 30 minutes. Stated, Im no longer bothered by the
voices.
ANS: B
, Problem-oriented documentation uses the first lette r of key words to
organize data: S for subjective data, O for objective data, A for
assessment, P for plan, I for intervention, and E for evaluation. The
distracters offer examples of P IE charting, focus documentation, and
narrative documentation.
PTS: 1 DIF: Cognitive Level: Anal yze (Anal ysis) REF: 120
TOP: Nursing Process: Implementation MSC: Client
Needs: Safe, Effective Care Environment
2. A nurse assesses an older adult patient brought to the emergency
department by a family member. The patient was wandering outside
saying, I cant find my way home. The patient is confused and unable to
answer questions. Select the nurses best action.
a. Record the patients answers to questions on the nursing assessment
form.
b. Ask an advanced practice nurse to perform the assessment
interview.
c. Call for a mental health advocate to maintain the patients rights.
d. Obtain important information from the famil y member.
ANS: D
When the patient (primary source) is unable to provide information,
secondary sources should be used, in this case, the famil y member.
Later, more data may be obtained from other information sources
familiar with the patient. An advanced practice nurse is not needed for
this assessment; it is within the scope of practice of the staff nurse.
Calling a mental health advocate is unnecessary. See relationship to
audience response question.
, PTS: 1 DIF: Cognitive Level: Appl y (Application)
REF: 111 TOP: Nursing Process: Assessment MSC:
Client Needs: Safe, Effective Care Environment
3. 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?
a. Behavior
b. Cognition
c. Affect and mood
d. Perceptual disturbances
ANS: B
Assessing cognition involves determining a patients judg ment and
decision making. In this case, the nurse would expect a response of
Call m y doctor if the patients cognition and judgment are intact. If the
patient responds, I would stop eating or I would just wait and see what
happened, the nurse would conclude that judgment is impaired. The
other options refer to other aspects of the examination.
PTS: 1 DIF: Cognitive Level: Appl y (Application)
REF: 114 TOP: Nursing Process: Assessment MSC:
Client Needs: Psychosocial Integrit y
4. An adolescent asks a nurse c onducting an assessment interview, Why
should I tell you anything? Youll just tell m y parents whatever you find
out. Which response by the nurse is appropriate?
