Varcarolis: Chapter 7 - The Nursing
Process and Standards of Care for
Psychiatric Mental Health Nursing
Questions and Correct 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. - correct answers: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 - correct answers: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. - correct answers: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. - correct answers: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. - correct answers: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 - correct answers: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. - correct
answers: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?
a. Report the findings to the health care provider.
b. Assess the patient for a history of renal problems.
c. Assess the patient's family history for cardiac problems.
d. Arrange for the patient's hospitalization on the psychiatric unit. - correct answers:ANS: B
Elevated BUN (blood urea nitrogen) and creatinine suggest renal problems. Renal dysfunction can often
imitate psychiatric disorders. The nurse should further assess the patient's history for renal problems and
then share the findings with the health care provider.
A patient states, "I'm not worth anything. I have negative thoughts about myself. I feel anxious and shaky
all the time. Sometimes I feel so sad that I want to go to sleep and never wake up." Which nursing
intervention should have the highest priority?
a. Self-esteem-building activities
Process and Standards of Care for
Psychiatric Mental Health Nursing
Questions and Correct 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. - correct answers: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 - correct answers: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. - correct answers: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. - correct answers: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. - correct answers: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 - correct answers: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. - correct
answers: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?
a. Report the findings to the health care provider.
b. Assess the patient for a history of renal problems.
c. Assess the patient's family history for cardiac problems.
d. Arrange for the patient's hospitalization on the psychiatric unit. - correct answers:ANS: B
Elevated BUN (blood urea nitrogen) and creatinine suggest renal problems. Renal dysfunction can often
imitate psychiatric disorders. The nurse should further assess the patient's history for renal problems and
then share the findings with the health care provider.
A patient states, "I'm not worth anything. I have negative thoughts about myself. I feel anxious and shaky
all the time. Sometimes I feel so sad that I want to go to sleep and never wake up." Which nursing
intervention should have the highest priority?
a. Self-esteem-building activities
