patient has a
Imbalanced right to know
nutrition, that mostand
hopelessness, information willself-esteem
chronic low be held in confidence
may be but
that certain
applicable material
nursing must be reported
diagnoses, but theseor shared with
problems theaffect
do not treatment team,
patient such
safety as
as threats
urgently asofwould
suicide, homicide,
a suicide use of illegal drugs, or issues of abuse. The
attempt.
HLTHASSESS Exam Questions
incorrect responses are not true, will not inspire theand Answers
confidence of the patient,
or are confrontational.
Question 3.
A patient diagnosed with major depression has lost 20 pounds in one month, has chronic
Question 1.
17. and a plan for suicide. The patient has taken an antidepressant
low self-esteem,
A new
nursestaff
wants
medication to
nurse
for assess
1 week. an adult
completes
Which an patient's
orientation
chiatric Mentalrecent
the memory.
to Health
psychiatric
NursingWhich
unit. question
This
nursing would
nurse
intervention best
will expect
has theto
yield
ask anthe
highest desired a.
advanced
priority? information?
practice
Implementnursea. "Where
to
suicide performdidwhich
you go
precautions. toOffer
action
b. elementary school?"
forhigh-calorie
patients? b. "What
a.snacks
Performand did
mental
fluids
you have
health
frequently.for
c.breakfast
assessment thethis morning?"
Assistinterviews.
patient c. "Can
b.toPrescribe
identify you name medication.
psychotropic
three personal the current president
strengths. c. Observe
d. ofpatient
Establish the for
United States?"
therapeutic d. "Aof few
relationships.
effects minutes
antidepressant ago,
d. Individualize I told you my
nursing
medication. carename.
plans.Can you remember it?"
Correct Answer: ANS: A B The patient'sprivileges
Prescriptive
Implementing recall of precautions
suicide aare
meal provides
granted istotheevidence of
master's-prepared
only option
recent memory. Two
nurse practitioners
related to patient incorrect
who
safety. have responses
The taken
other are
special
options, useful on
courses
related to
to assess immediate
prescribing
nutrition, and
medication.
self-esteem,
remote memory.
The nurse
and Theatother
prepared
medication therapy, the distracter
basic
are level assesses
important but are the
performs patient's
mental
not health
priorities. fund of knowledge.
assessments,
establishes relationships, and provides individualized care planning. Note that
Question 2.
this question
18.was also offered for Chapter 1.
4.
When
The a nurse
desired assesses
outcome foran older adult
a patient patient, answers
experiencing insomnia seem vague or
is, "Patient unrelated
will sleep fortoa the
Question
questions.of
minimum 2.
The patient
5 hours also leans
nightly withinforward
7 days."and
At frowns,
the endlistening
of 7 days, intently
reviewto ofthe nurse.
sleep dataAn
appropriate
A newly
shows the question
admitted
patient for the
patient
sleeps nurse towith
diagnosed
an average ask
of would
4 major be: a. "Are
and you
depression
hours nightly has
takes having
gained difficulty
20
a 2-hour pounds hearing
afternoonover a
nap.
few months
when
The I speak?"
nurse and
will chiatric
has suicidal
document Mental
the ideation.
Health Nursing
outcome The patient
as: a. b. "How
has taken
consistently can I make
an antidepressant
demonstrated.this assessment
b. oftenmedication
interview
for 1 weekeasier
demonstrated. c.for
without you?" c. "Idemonstrated.
remission
sometimes ofnotice you are
symptoms. d.frowning.
Select Are you
thedemonstrated.
never priority feelingdiagnosis.
nursing annoyed witha. me?"
patient is annoyed, the nurse is jumping to conclusions. Asking how to make the
Imbalanced
d. "You're having
nutrition:
troublemorefocusing
than body
on what
requirements
I'm saying. b. What
Chronic is distracting
low self-esteem
you?" c. Risk for
interview easier ANS:
Correct Answer: for the D patient
Although maythenot elicitis
patient a sleeping
concrete 6 answer. Asking
hours daily, theabout
total
suicide d. Hopelessness
distractions
Correct
is not one is
Answer: a way of
ANS: A The
uninterrupted asking about
patient's
session auditory
behaviors
at night. hallucinations,
may indicate
Therefore, the outcome which is
difficulty not
musthearing.
be
evaluated
appropriate as
Correct Answer:
Identifying any never
because demonstrated.
physical
ANS: the nurse
C Risk
need for has
the See
suicide
patientrelationship
observed thethat
is may the
priority
have to audience
atpatient
diagnosis
the onset response
seems
when tothe
of the be
interview
question.
listening
patient
and intently.
has
making both suicidal ideation
accommodations and a planconsiderations.
are important to carry out theBy suicidal
askingintent.
if the
Imbalanced nutrition, hopelessness, and chronic low self-esteem may be
applicable 3.
Question nursing diagnoses, but these problems do not affect patient safety as
5.
19.
12.
urgently as would a suicide attempt.
Thewhat
At
Whichdesired
pointoutcome
statement in an made forbya patient
assessment a patient experiencing
interview
during would insomnia
a nurse
an initial is, "Patient
ask,
assessment "Howinterview
doeswillyour
sleep for help
faith
should a
serve you
as
minimum
in
thestressful
priority ofsituations?"
5 hours
focus for nightlyplanwithin
theDuring ofthe 7
care? days."
assessment At the
a. "I can of: end
always of 7 days,
a. childhood
trust my growthreviewand
family." of "It
b. sleep datalike Ib.
development
seems
Question
shows the
substance
always have 3.
patient
usebadand sleeps
abuse
luck." c. an average
never of
c. educational
"You know4background
hours
who nightly d. and
will turn coping takes
against a 2-hour
strategies
you." d. "I afternoon nap.
hear evil voices
What
that
A is the
tell
patient me nurse's
to do bad
diagnosed next
with action?
things." a. Continue
majorchiatric
depressionMentalhasthe current
Health
lost 20 plan without
Nursing
pounds in one changes.
month, has b. chronic
Remove
Correct Answer: ANS: D When discussing coping strategies, the nurse might ask
this self-esteem,
low nursing diagnosis and afrom plan the plan of care.
for suicide. c. Writehas
The patient a newtakennursing diagnosis that better
an antidepressant
what the
Correct patientANS:
Answer: does D when upset, what
The statement usually relieves
regarding evil voices stress,
tellsand theto whom
nurse that
reflects the for
medication problem.
1 week. chiatric
WhichMental
chiatricHealth
MentalNursing
Health d. Examine
Nursing interventions
nursing interventionfor possible
has the
the patient is goes to talk about
experiencing problems.
auditory The question
hallucinations andregarding
may create whether
risks for the
revision priority?
highest of the target date.
a. Implement suicide precautions. b. Offer high-calorie snacks and fluids
patient's faith
violence. helpsstatements
The other deal with stress are vaguefits wellandhere.
do not It would
clearlybe out ofthe
identify place if
frequently. c. Assist the patient to identify three personal strengths. d. Observe patient for
Correct Answer:
introduced
patient's during
chief ANS:
symptom. D Sleeping
exploration a total
of the other of topics.
5 hours at night remains a
therapeutic effects of antidepressant medication.
reasonable outcome. Extending the period for attaining the outcome may be
Question
appropriate.
Correct 4.
Answer:
20.
13. Examining
ANS: A interventions
Implementing might suicide result in planning
precautions is the anonly
activity
optionduring
the afternoon
related to patientrather thanThe
safety. permitting a nap. Continuing
other options, the current
related to nutrition, plan without
self-esteem,
When aentry
Which new in patient is hospitalized,
the medical record best a nurse
meets takes the patient on
the requirement fora problem-oriented
tour, explains rules of
changes
and is inappropriate.
medication therapy, are Removing
important thisbut nursing
are not diagnosis
priorities. from the plan of care
the unit, and
charting? discusses
a. "A: Pacing and the daily schedule.
muttering The
to self. P:nurse
Sensoryis engaged
perceptual in: alteration
a. counseling. chiatric
related to
would be correct when the outcome was met and the problem resolved. Writing
Mental Health
internal auditory Nursing b. health
stimulation. teaching.
I: Given c. milieu management.
fluphenazine HCL (Prolixin) 2.5 d. psychobiological
mg po at 0900 and
a new nursing
Question 4.to diagnosis is inappropriate because no other nursing diagnosis
intervention.
went to room lie down. E: Calmer by 0930. Returned to lounge to watch TV." b. "S:
relates to the problem.
States, 'I feeloutcome
The desired like I'm ready to blowexperiencing
for a patient up.' O: Pacing hall, mumbling
insomnia is, "Patient to self.
will A: Auditory
sleep for a
Correct Answer: ANS: C Milieu management provides a therapeutic environment
hallucinations.
minimum of 5 hours P: Offer haloperidol
nightly within 7 (Haldol)
days." 2 Atmgthepo.
endI: of
Haloperidol
7 days, review (Haldol) 2 mg data
of sleep po given
in which the
Question 6. patient can feel comfortable and safe while engaging in activities
at 0900.
shows the E:patient
Returned to lounge
sleeps at 0930
an average of and quietly
4 hours watched
nightly TV." c.
and takes "Agitated
a 2-hour behavior.
afternoon nap.D:
that meet the patient's physical and mental health needs. Counseling refers to
A
Thepatient
Patient
nurse begins
muttering atonew
will document selfprogram
as
thethough to assist
outcome as: with
answering building
an unseen
a. consistently social skills.
person.
demonstrated. A:In which
Given part of the
b. haloperidol
often
activities designed to promote problem solving and enhanced coping and
plan of care
(Haldol) 2 mg
demonstrated. should
po
c. and a nurse
went to
sometimes record
roomthe
demonstrated. item,
to lie "Encourage
down. E: Patient
d. never patient
calmer.
demonstrated. toReturned
attend one to lounge to
includes interviewing, crisis intervention, stress management, and conflict
psychoeducational
watch TV." d. "Pacing group
hall daily"? a. Assessment
and muttering to self asb. Analysis
though c. Implementation d.
resolution.
Correct Answer: Health ANS:teaching
D Althoughinvolves theidentifying health education
patient is sleeping 6 hours daily, needsthe andtotal
Evaluation
giving
Correct
is not oneinformation
Answer: ingabout
uninterrupted these person.
an unseen
session needs.
at night. Psychobiological
haloperidol
Therefore, theinterventions
(Haldol) 2 mg po
outcome must involve
be
Correct Answer:
medication
administered ANS: with
administration
at 0900 C Interventions
and
calmingmonitoring are in
effect the
response
30 nursing
minutes. toprescriptions
Stated, 'I'mto
medications. noachieve
longer
the outcomes.
bothered by the Interventions
voices.'" ANS: should be specific.
B Problem-oriented documentation uses the first
letter of key words to organize data: S for subjective data, O for objective data,
, A nurse wants to assess an adult patient's recent memory. Which question would best
Correct Answer: ing an unseen person. haloperidol (Haldol) 2 mg po
yield the desired information? a. "Where did you go to elementary school?" b. "What did
administered at 0900 with calming effect in 30 minutes. Stated, 'I'm no longer
you have for breakfast this morning?" c. "Can you name the current president of the
bothered by the voices.'" ANS: B Problem-oriented documentation uses the first
United States?" d. "A few minutes ago, I told you my name. Can you remember it?"
letter of key words to organize data: S for subjective data, O for objective data,
Correct Answer: ANS:
A for assessment, B plan,
P for The patient's recall of a and
I for intervention, mealE provides evidence
for evaluation. Theof
recent memory.
distracters offer Two incorrect
examples responses
of PIE are
charting, useful
focus to assess immediate
documentation, and
and narrative
remote memory. The other distracter assesses the patient's fund of knowledge.
documentation.
Question 5.
18.
14.
When
A nurse a nurse
assesses assesses
an older an adult
older patient
adult patient,
brought answers seem vague
to the emergency or unrelated
department byto a the
family
questions.
member. The Thepatient
patientwas alsowandering
leans forward outside andsaying,
frowns,"Ilistening
can't find intently
my way to home."
the nurse. TheAn
appropriate
patient is confusedquestion and forchiatric
the nurse to ask
Mental would
Health be: a. "Are
Nursing unable youtohaving
answer difficulty
questions. hearing
Select
when I speak?"
the nurse's bestchiatric
action. Mentala. Record Health Nursing b.
the patient's "How can
answers I make this
to questions onassessment
the nursing
interview
assessment easier
form. forb.you?"
Ask an c. advanced
"I notice you are frowning.
practice nurse to Are you feeling
perform annoyed with
the assessment me?"
interview.
d. "You're
c. Call for ahaving
mental trouble
healthfocusing
advocate ontowhat I'm saying.
maintain What isrights.
the patient's distracting
d. Obtain you?" important
information from the family member.
Correct Answer: ANS: A The patient's behaviors may indicate difficulty hearing.
Identifying
Correct Answer: any physical
ANS: D When need the the patient
patient may (primaryhavesource)
at the onset is unable of the tointerview
provide
evaluated
and making accommodations
information, as never demonstrated.
secondary sources areshould See
important relationship
be used, to
considerations. audience
in this case,By the response
asking
familyifmember. the
patient
question. is annoyed, the nurse is jumping
Later, more data may be obtained from other information sources familiar withto conclusions. Asking how to make the
interview
the patient. easier for the patient
An advanced practice may nursenot elicit
is notaneededconcrete foranswer. Asking about
this assessment; it is
distractions
within the 5.
Question 8. is a way
scope of asking
of practice of about
the staff auditory
nurse.hallucinations,
Calling a mental which
health is not advocate
appropriate
is unnecessary. because See the nurse has
relationship to observed
audience that the patient
response question. seems to be
A patient
The desired presents
outcome to the
for aemergency department
patient experiencing with
insomnia mixed psychiatric
is, "Patient will symptoms.
sleep for a The
listening intently.
admissionof
minimum nurse
5 hours suspects
nightly the symptoms
within 7 days." may At bethethe endresult of a medical
of 7 days, review of problem.
sleep data Lab
results the
shows show elevated
patient sleeps BUN an(blood
average urea of nitrogen)
4 hours nightly and creatinine.
and takesWhat is the
a 2-hour nurse's next
afternoon nap.
Question
best action?
What 6.
29.
19.
a. Report
is the nurse's next theaction?
findings a. to the health
Continue the care
currentprovider. b. Assess
plan without the patient
changes. b. Removefor a
Select
At what
history
this all
of
nursing that
point
renal inapply.
diagnosis What
an assessment
problems. fromc. information
interview
Assess
the plan the ispatient's
of care. conveyed
would by
afamily
c. Write a nursing
nurse new diagnoses?
ask,nursing
history "Howfor does
cardiac your
diagnosis a. Medical
faith
that help
problems. d.you
better
judgments
in stressful
Arrange
reflects forabout
the the disorder
situations?"
the patient's
problem. During b.
theUnmet
hospitalization
chiatric Mental assessment
Healthpatient
on the needs
of:
Nursing a.d. currently
childhood
psychiatric Examine present
unit.growth and
interventions chiatric forMental
development possibleb.
Health
substance
revision Nursing
of use c. Goals
and
the target abusedate.and outcomes forbackground
c. educational the plan of d. care d. Supporting
coping strategiesdata that validate
Correct Answer: ANS: B Elevated BUN (blood urea nitrogen) and creatinine
the diagnoses e. Probable causes that will be targets for nursing interventions
suggestAnswer:
Correct renal problems. ANS: D Sleeping When
Renaldiscussing
dysfunction
a total of coping
can
5 hours strategies,
often at imitate the
night remains nurse
psychiatric a might ask
Correct
what the
disorders.
reasonable Answer:
patient
The ANS:
nurse
outcome. doesshouldB, D, Efurther
when
Extending Nursing
upset,thewhat diagnoses
assess
period usually focus
relieves
theattaining
for patient's onthe phenomena
stress,
historyoutcome andrenal
for toofwhom
may concern
be
to
thenurses
patient
problems
appropriate. rather
andgoes then than
to share
Examining talk oninterventions
medical
about diagnoses.
problems.
the findings with
might The the question
health
result regarding
care
in planning anwhether
provider. activity during the
patient's
the afternoon faith rather
helps deal thanwith stress fits
permitting a nap. wellContinuing
here. It would be out of
the current plan place if
without
Question
introduced
changes is 7. during exploration
inappropriate.
30.
9. of the this
Removing other topics.diagnosis from the plan of care
nursing
would be correct when the outcome was met and the problem resolved. Writing
Select
A patientall states,
that apply. "I'm Anot patient
worthisanything.
very suspicious and states,
I have negative "The FBI
thoughts has myself.
about me under I feel
a new nursing
Question diagnosis is inappropriate because no other nursing diagnosis
anxious and20.
surveillance." Which
shaky allstrategies
the time. should
Sometimes a nurse use
I feel sowhen
sad thatgathering
I want initial
to go assessment
to sleep and data
relates to the problem.
about
When wake
never this
a new patient?
patient
up." Whicha.isTell the patient
hospitalized,
nursing a that
nurse
intervention medication
takes
shouldthe will
have help
patient
the this
on
highest type
a tour, of thinking.
explains
priority? a. rules b. of
Ask
the patient,
unit, and"Tell
Self-esteem-building me about
discusses activities theb.
the daily problem
Anxietyas
schedule. you nurse
The see it."
self-control isc. Seek information
engaged
measures c.in: about when
a. counseling.
Sleep enhancement the
chiatric
Question
problem
Mental Health
activities began.6.
d. Suicide d. Tell
Nursing thehealth
b.
precautions patient, "YourMental
teaching.
chiatric ideas are
c. milieuHealthnot realistic." e.
management.
Nursing d.Reassure
psychobiologicalthe patient,
"You are safe
intervention.
A patient begins here." a new program to assist with building social skills. In which part of the
Correct Answer: ANS: D The nurse would place a priority on monitoring and
plan of care should a nurse record the item, "Encourage patient to attend one
Correct Answer:
reinforcing suicide ANS: B, C, E During
C Milieu
self-restraint management
because the assessment provides
it relates interview, and the
a therapeutic
directly nurse
environment
immediately shouldto
psychoeducational group daily"? a. Assessment b. Analysis c. Implementation d.
listen
in which
patient attentively
the patient
safety. andcan
Patient accept the
feel comfortable
safety patient's
is always statements
and
a priority safeconcern.
while in engaging
a Thenonjudgmental
nurse in should
activitiesway.
Evaluation
Because
that meet
monitor the
and the patient
patient's
reinforce is all
suspicious
physical
patientand andmental
attempts fearful, reassuring
tohealth
control needs.
anxiety,safety
Counseling may be
improve helpful,
refers
sleep to
although
activities
patterns,
Correct trust
designed
Answer: isANS:
and develop unlikely
to C so early
promote
self-esteem,
Interventions inwhile
problem theare relationship.
solving
giving
the nursingand
priority Saying
enhanced
attention
prescriptions that
coping medication
toto and
suicide
achieve
will help interviewing,
includes
self-restraint.
the outcomes.or telling the patient
Interventions that the
crisis intervention,
should be ideas are management,
stress
specific. not realistic will and undermine
conflict
development
resolution. Health of trust between
teaching the nurse
involves and patient.
identifying health education needs and
Question
giving information 8.
10.
7. about these needs. Psychobiological interventions involve
medication31.
Question administration and monitoring response to medications.
Select the
Before best outcome
assessing for a patient
a new patient, a nurse with the nursing
is told by another diagnosis:
health Impaired
care worker, social "I know that
1. What No
interaction
patient. is the purpose
related
matter of thewe
to sociocultural
how hard Health Insurance
dissonance
work, there isn't Portability
as evidenced
much and byAccountability
improvement stating, by"Although
the timeAct (HIPAA)?
I'd like
of
Question
Select
to, all that
I don't
discharge." join21.
The apply.
in because
nurse's a. Ensuring that an
I don't speak
responsibility istheindividual's
to: language
a. document health
verythe information
well."
other Patient
worker'sis
will:protected
a. show b. of
assessment
Providing
Afterpatient.
improved
the third-party
formulating
use b. of the players
language.
assess nursing b.with
the patient accesson
diagnoses
demonstrate
based toimproved
for apatient's
datanew medical
patient,
collected what
socialfrom records
skills. isc.
all c. Facilitating
a become
nurse's
sources. c.next
more
validate thethea.
action?
movement ofin
Designingimpression
independent
worker's a decision
patient's
interventions medical
to include
making.
by contacting chiatric
d. in the
select
the Mental
plan
and of
patient's Health
care
participateb. Nursing
significant one information
Determining
inother. group the
chiatric goals
activity to and
Mental the
per day.
Health
Imbalanced right to know
nutrition, that mostand
hopelessness, information willself-esteem
chronic low be held in confidence
may be but
that certain
applicable material
nursing must be reported
diagnoses, but theseor shared with
problems theaffect
do not treatment team,
patient such
safety as
as threats
urgently asofwould
suicide, homicide,
a suicide use of illegal drugs, or issues of abuse. The
attempt.
HLTHASSESS Exam Questions
incorrect responses are not true, will not inspire theand Answers
confidence of the patient,
or are confrontational.
Question 3.
A patient diagnosed with major depression has lost 20 pounds in one month, has chronic
Question 1.
17. and a plan for suicide. The patient has taken an antidepressant
low self-esteem,
A new
nursestaff
wants
medication to
nurse
for assess
1 week. an adult
completes
Which an patient's
orientation
chiatric Mentalrecent
the memory.
to Health
psychiatric
NursingWhich
unit. question
This
nursing would
nurse
intervention best
will expect
has theto
yield
ask anthe
highest desired a.
advanced
priority? information?
practice
Implementnursea. "Where
to
suicide performdidwhich
you go
precautions. toOffer
action
b. elementary school?"
forhigh-calorie
patients? b. "What
a.snacks
Performand did
mental
fluids
you have
health
frequently.for
c.breakfast
assessment thethis morning?"
Assistinterviews.
patient c. "Can
b.toPrescribe
identify you name medication.
psychotropic
three personal the current president
strengths. c. Observe
d. ofpatient
Establish the for
United States?"
therapeutic d. "Aof few
relationships.
effects minutes
antidepressant ago,
d. Individualize I told you my
nursing
medication. carename.
plans.Can you remember it?"
Correct Answer: ANS: A B The patient'sprivileges
Prescriptive
Implementing recall of precautions
suicide aare
meal provides
granted istotheevidence of
master's-prepared
only option
recent memory. Two
nurse practitioners
related to patient incorrect
who
safety. have responses
The taken
other are
special
options, useful on
courses
related to
to assess immediate
prescribing
nutrition, and
medication.
self-esteem,
remote memory.
The nurse
and Theatother
prepared
medication therapy, the distracter
basic
are level assesses
important but are the
performs patient's
mental
not health
priorities. fund of knowledge.
assessments,
establishes relationships, and provides individualized care planning. Note that
Question 2.
this question
18.was also offered for Chapter 1.
4.
When
The a nurse
desired assesses
outcome foran older adult
a patient patient, answers
experiencing insomnia seem vague or
is, "Patient unrelated
will sleep fortoa the
Question
questions.of
minimum 2.
The patient
5 hours also leans
nightly withinforward
7 days."and
At frowns,
the endlistening
of 7 days, intently
reviewto ofthe nurse.
sleep dataAn
appropriate
A newly
shows the question
admitted
patient for the
patient
sleeps nurse towith
diagnosed
an average ask
of would
4 major be: a. "Are
and you
depression
hours nightly has
takes having
gained difficulty
20
a 2-hour pounds hearing
afternoonover a
nap.
few months
when
The I speak?"
nurse and
will chiatric
has suicidal
document Mental
the ideation.
Health Nursing
outcome The patient
as: a. b. "How
has taken
consistently can I make
an antidepressant
demonstrated.this assessment
b. oftenmedication
interview
for 1 weekeasier
demonstrated. c.for
without you?" c. "Idemonstrated.
remission
sometimes ofnotice you are
symptoms. d.frowning.
Select Are you
thedemonstrated.
never priority feelingdiagnosis.
nursing annoyed witha. me?"
patient is annoyed, the nurse is jumping to conclusions. Asking how to make the
Imbalanced
d. "You're having
nutrition:
troublemorefocusing
than body
on what
requirements
I'm saying. b. What
Chronic is distracting
low self-esteem
you?" c. Risk for
interview easier ANS:
Correct Answer: for the D patient
Although maythenot elicitis
patient a sleeping
concrete 6 answer. Asking
hours daily, theabout
total
suicide d. Hopelessness
distractions
Correct
is not one is
Answer: a way of
ANS: A The
uninterrupted asking about
patient's
session auditory
behaviors
at night. hallucinations,
may indicate
Therefore, the outcome which is
difficulty not
musthearing.
be
evaluated
appropriate as
Correct Answer:
Identifying any never
because demonstrated.
physical
ANS: the nurse
C Risk
need for has
the See
suicide
patientrelationship
observed thethat
is may the
priority
have to audience
atpatient
diagnosis
the onset response
seems
when tothe
of the be
interview
question.
listening
patient
and intently.
has
making both suicidal ideation
accommodations and a planconsiderations.
are important to carry out theBy suicidal
askingintent.
if the
Imbalanced nutrition, hopelessness, and chronic low self-esteem may be
applicable 3.
Question nursing diagnoses, but these problems do not affect patient safety as
5.
19.
12.
urgently as would a suicide attempt.
Thewhat
At
Whichdesired
pointoutcome
statement in an made forbya patient
assessment a patient experiencing
interview
during would insomnia
a nurse
an initial is, "Patient
ask,
assessment "Howinterview
doeswillyour
sleep for help
faith
should a
serve you
as
minimum
in
thestressful
priority ofsituations?"
5 hours
focus for nightlyplanwithin
theDuring ofthe 7
care? days."
assessment At the
a. "I can of: end
always of 7 days,
a. childhood
trust my growthreviewand
family." of "It
b. sleep datalike Ib.
development
seems
Question
shows the
substance
always have 3.
patient
usebadand sleeps
abuse
luck." c. an average
never of
c. educational
"You know4background
hours
who nightly d. and
will turn coping takes
against a 2-hour
strategies
you." d. "I afternoon nap.
hear evil voices
What
that
A is the
tell
patient me nurse's
to do bad
diagnosed next
with action?
things." a. Continue
majorchiatric
depressionMentalhasthe current
Health
lost 20 plan without
Nursing
pounds in one changes.
month, has b. chronic
Remove
Correct Answer: ANS: D When discussing coping strategies, the nurse might ask
this self-esteem,
low nursing diagnosis and afrom plan the plan of care.
for suicide. c. Writehas
The patient a newtakennursing diagnosis that better
an antidepressant
what the
Correct patientANS:
Answer: does D when upset, what
The statement usually relieves
regarding evil voices stress,
tellsand theto whom
nurse that
reflects the for
medication problem.
1 week. chiatric
WhichMental
chiatricHealth
MentalNursing
Health d. Examine
Nursing interventions
nursing interventionfor possible
has the
the patient is goes to talk about
experiencing problems.
auditory The question
hallucinations andregarding
may create whether
risks for the
revision priority?
highest of the target date.
a. Implement suicide precautions. b. Offer high-calorie snacks and fluids
patient's faith
violence. helpsstatements
The other deal with stress are vaguefits wellandhere.
do not It would
clearlybe out ofthe
identify place if
frequently. c. Assist the patient to identify three personal strengths. d. Observe patient for
Correct Answer:
introduced
patient's during
chief ANS:
symptom. D Sleeping
exploration a total
of the other of topics.
5 hours at night remains a
therapeutic effects of antidepressant medication.
reasonable outcome. Extending the period for attaining the outcome may be
Question
appropriate.
Correct 4.
Answer:
20.
13. Examining
ANS: A interventions
Implementing might suicide result in planning
precautions is the anonly
activity
optionduring
the afternoon
related to patientrather thanThe
safety. permitting a nap. Continuing
other options, the current
related to nutrition, plan without
self-esteem,
When aentry
Which new in patient is hospitalized,
the medical record best a nurse
meets takes the patient on
the requirement fora problem-oriented
tour, explains rules of
changes
and is inappropriate.
medication therapy, are Removing
important thisbut nursing
are not diagnosis
priorities. from the plan of care
the unit, and
charting? discusses
a. "A: Pacing and the daily schedule.
muttering The
to self. P:nurse
Sensoryis engaged
perceptual in: alteration
a. counseling. chiatric
related to
would be correct when the outcome was met and the problem resolved. Writing
Mental Health
internal auditory Nursing b. health
stimulation. teaching.
I: Given c. milieu management.
fluphenazine HCL (Prolixin) 2.5 d. psychobiological
mg po at 0900 and
a new nursing
Question 4.to diagnosis is inappropriate because no other nursing diagnosis
intervention.
went to room lie down. E: Calmer by 0930. Returned to lounge to watch TV." b. "S:
relates to the problem.
States, 'I feeloutcome
The desired like I'm ready to blowexperiencing
for a patient up.' O: Pacing hall, mumbling
insomnia is, "Patient to self.
will A: Auditory
sleep for a
Correct Answer: ANS: C Milieu management provides a therapeutic environment
hallucinations.
minimum of 5 hours P: Offer haloperidol
nightly within 7 (Haldol)
days." 2 Atmgthepo.
endI: of
Haloperidol
7 days, review (Haldol) 2 mg data
of sleep po given
in which the
Question 6. patient can feel comfortable and safe while engaging in activities
at 0900.
shows the E:patient
Returned to lounge
sleeps at 0930
an average of and quietly
4 hours watched
nightly TV." c.
and takes "Agitated
a 2-hour behavior.
afternoon nap.D:
that meet the patient's physical and mental health needs. Counseling refers to
A
Thepatient
Patient
nurse begins
muttering atonew
will document selfprogram
as
thethough to assist
outcome as: with
answering building
an unseen
a. consistently social skills.
person.
demonstrated. A:In which
Given part of the
b. haloperidol
often
activities designed to promote problem solving and enhanced coping and
plan of care
(Haldol) 2 mg
demonstrated. should
po
c. and a nurse
went to
sometimes record
roomthe
demonstrated. item,
to lie "Encourage
down. E: Patient
d. never patient
calmer.
demonstrated. toReturned
attend one to lounge to
includes interviewing, crisis intervention, stress management, and conflict
psychoeducational
watch TV." d. "Pacing group
hall daily"? a. Assessment
and muttering to self asb. Analysis
though c. Implementation d.
resolution.
Correct Answer: Health ANS:teaching
D Althoughinvolves theidentifying health education
patient is sleeping 6 hours daily, needsthe andtotal
Evaluation
giving
Correct
is not oneinformation
Answer: ingabout
uninterrupted these person.
an unseen
session needs.
at night. Psychobiological
haloperidol
Therefore, theinterventions
(Haldol) 2 mg po
outcome must involve
be
Correct Answer:
medication
administered ANS: with
administration
at 0900 C Interventions
and
calmingmonitoring are in
effect the
response
30 nursing
minutes. toprescriptions
Stated, 'I'mto
medications. noachieve
longer
the outcomes.
bothered by the Interventions
voices.'" ANS: should be specific.
B Problem-oriented documentation uses the first
letter of key words to organize data: S for subjective data, O for objective data,
, A nurse wants to assess an adult patient's recent memory. Which question would best
Correct Answer: ing an unseen person. haloperidol (Haldol) 2 mg po
yield the desired information? a. "Where did you go to elementary school?" b. "What did
administered at 0900 with calming effect in 30 minutes. Stated, 'I'm no longer
you have for breakfast this morning?" c. "Can you name the current president of the
bothered by the voices.'" ANS: B Problem-oriented documentation uses the first
United States?" d. "A few minutes ago, I told you my name. Can you remember it?"
letter of key words to organize data: S for subjective data, O for objective data,
Correct Answer: ANS:
A for assessment, B plan,
P for The patient's recall of a and
I for intervention, mealE provides evidence
for evaluation. Theof
recent memory.
distracters offer Two incorrect
examples responses
of PIE are
charting, useful
focus to assess immediate
documentation, and
and narrative
remote memory. The other distracter assesses the patient's fund of knowledge.
documentation.
Question 5.
18.
14.
When
A nurse a nurse
assesses assesses
an older an adult
older patient
adult patient,
brought answers seem vague
to the emergency or unrelated
department byto a the
family
questions.
member. The Thepatient
patientwas alsowandering
leans forward outside andsaying,
frowns,"Ilistening
can't find intently
my way to home."
the nurse. TheAn
appropriate
patient is confusedquestion and forchiatric
the nurse to ask
Mental would
Health be: a. "Are
Nursing unable youtohaving
answer difficulty
questions. hearing
Select
when I speak?"
the nurse's bestchiatric
action. Mentala. Record Health Nursing b.
the patient's "How can
answers I make this
to questions onassessment
the nursing
interview
assessment easier
form. forb.you?"
Ask an c. advanced
"I notice you are frowning.
practice nurse to Are you feeling
perform annoyed with
the assessment me?"
interview.
d. "You're
c. Call for ahaving
mental trouble
healthfocusing
advocate ontowhat I'm saying.
maintain What isrights.
the patient's distracting
d. Obtain you?" important
information from the family member.
Correct Answer: ANS: A The patient's behaviors may indicate difficulty hearing.
Identifying
Correct Answer: any physical
ANS: D When need the the patient
patient may (primaryhavesource)
at the onset is unable of the tointerview
provide
evaluated
and making accommodations
information, as never demonstrated.
secondary sources areshould See
important relationship
be used, to
considerations. audience
in this case,By the response
asking
familyifmember. the
patient
question. is annoyed, the nurse is jumping
Later, more data may be obtained from other information sources familiar withto conclusions. Asking how to make the
interview
the patient. easier for the patient
An advanced practice may nursenot elicit
is notaneededconcrete foranswer. Asking about
this assessment; it is
distractions
within the 5.
Question 8. is a way
scope of asking
of practice of about
the staff auditory
nurse.hallucinations,
Calling a mental which
health is not advocate
appropriate
is unnecessary. because See the nurse has
relationship to observed
audience that the patient
response question. seems to be
A patient
The desired presents
outcome to the
for aemergency department
patient experiencing with
insomnia mixed psychiatric
is, "Patient will symptoms.
sleep for a The
listening intently.
admissionof
minimum nurse
5 hours suspects
nightly the symptoms
within 7 days." may At bethethe endresult of a medical
of 7 days, review of problem.
sleep data Lab
results the
shows show elevated
patient sleeps BUN an(blood
average urea of nitrogen)
4 hours nightly and creatinine.
and takesWhat is the
a 2-hour nurse's next
afternoon nap.
Question
best action?
What 6.
29.
19.
a. Report
is the nurse's next theaction?
findings a. to the health
Continue the care
currentprovider. b. Assess
plan without the patient
changes. b. Removefor a
Select
At what
history
this all
of
nursing that
point
renal inapply.
diagnosis What
an assessment
problems. fromc. information
interview
Assess
the plan the ispatient's
of care. conveyed
would by
afamily
c. Write a nursing
nurse new diagnoses?
ask,nursing
history "Howfor does
cardiac your
diagnosis a. Medical
faith
that help
problems. d.you
better
judgments
in stressful
Arrange
reflects forabout
the the disorder
situations?"
the patient's
problem. During b.
theUnmet
hospitalization
chiatric Mental assessment
Healthpatient
on the needs
of:
Nursing a.d. currently
childhood
psychiatric Examine present
unit.growth and
interventions chiatric forMental
development possibleb.
Health
substance
revision Nursing
of use c. Goals
and
the target abusedate.and outcomes forbackground
c. educational the plan of d. care d. Supporting
coping strategiesdata that validate
Correct Answer: ANS: B Elevated BUN (blood urea nitrogen) and creatinine
the diagnoses e. Probable causes that will be targets for nursing interventions
suggestAnswer:
Correct renal problems. ANS: D Sleeping When
Renaldiscussing
dysfunction
a total of coping
can
5 hours strategies,
often at imitate the
night remains nurse
psychiatric a might ask
Correct
what the
disorders.
reasonable Answer:
patient
The ANS:
nurse
outcome. doesshouldB, D, Efurther
when
Extending Nursing
upset,thewhat diagnoses
assess
period usually focus
relieves
theattaining
for patient's onthe phenomena
stress,
historyoutcome andrenal
for toofwhom
may concern
be
to
thenurses
patient
problems
appropriate. rather
andgoes then than
to share
Examining talk oninterventions
medical
about diagnoses.
problems.
the findings with
might The the question
health
result regarding
care
in planning anwhether
provider. activity during the
patient's
the afternoon faith rather
helps deal thanwith stress fits
permitting a nap. wellContinuing
here. It would be out of
the current plan place if
without
Question
introduced
changes is 7. during exploration
inappropriate.
30.
9. of the this
Removing other topics.diagnosis from the plan of care
nursing
would be correct when the outcome was met and the problem resolved. Writing
Select
A patientall states,
that apply. "I'm Anot patient
worthisanything.
very suspicious and states,
I have negative "The FBI
thoughts has myself.
about me under I feel
a new nursing
Question diagnosis is inappropriate because no other nursing diagnosis
anxious and20.
surveillance." Which
shaky allstrategies
the time. should
Sometimes a nurse use
I feel sowhen
sad thatgathering
I want initial
to go assessment
to sleep and data
relates to the problem.
about
When wake
never this
a new patient?
patient
up." Whicha.isTell the patient
hospitalized,
nursing a that
nurse
intervention medication
takes
shouldthe will
have help
patient
the this
on
highest type
a tour, of thinking.
explains
priority? a. rules b. of
Ask
the patient,
unit, and"Tell
Self-esteem-building me about
discusses activities theb.
the daily problem
Anxietyas
schedule. you nurse
The see it."
self-control isc. Seek information
engaged
measures c.in: about when
a. counseling.
Sleep enhancement the
chiatric
Question
problem
Mental Health
activities began.6.
d. Suicide d. Tell
Nursing thehealth
b.
precautions patient, "YourMental
teaching.
chiatric ideas are
c. milieuHealthnot realistic." e.
management.
Nursing d.Reassure
psychobiologicalthe patient,
"You are safe
intervention.
A patient begins here." a new program to assist with building social skills. In which part of the
Correct Answer: ANS: D The nurse would place a priority on monitoring and
plan of care should a nurse record the item, "Encourage patient to attend one
Correct Answer:
reinforcing suicide ANS: B, C, E During
C Milieu
self-restraint management
because the assessment provides
it relates interview, and the
a therapeutic
directly nurse
environment
immediately shouldto
psychoeducational group daily"? a. Assessment b. Analysis c. Implementation d.
listen
in which
patient attentively
the patient
safety. andcan
Patient accept the
feel comfortable
safety patient's
is always statements
and
a priority safeconcern.
while in engaging
a Thenonjudgmental
nurse in should
activitiesway.
Evaluation
Because
that meet
monitor the
and the patient
patient's
reinforce is all
suspicious
physical
patientand andmental
attempts fearful, reassuring
tohealth
control needs.
anxiety,safety
Counseling may be
improve helpful,
refers
sleep to
although
activities
patterns,
Correct trust
designed
Answer: isANS:
and develop unlikely
to C so early
promote
self-esteem,
Interventions inwhile
problem theare relationship.
solving
giving
the nursingand
priority Saying
enhanced
attention
prescriptions that
coping medication
toto and
suicide
achieve
will help interviewing,
includes
self-restraint.
the outcomes.or telling the patient
Interventions that the
crisis intervention,
should be ideas are management,
stress
specific. not realistic will and undermine
conflict
development
resolution. Health of trust between
teaching the nurse
involves and patient.
identifying health education needs and
Question
giving information 8.
10.
7. about these needs. Psychobiological interventions involve
medication31.
Question administration and monitoring response to medications.
Select the
Before best outcome
assessing for a patient
a new patient, a nurse with the nursing
is told by another diagnosis:
health Impaired
care worker, social "I know that
1. What No
interaction
patient. is the purpose
related
matter of thewe
to sociocultural
how hard Health Insurance
dissonance
work, there isn't Portability
as evidenced
much and byAccountability
improvement stating, by"Although
the timeAct (HIPAA)?
I'd like
of
Question
Select
to, all that
I don't
discharge." join21.
The apply.
in because
nurse's a. Ensuring that an
I don't speak
responsibility istheindividual's
to: language
a. document health
verythe information
well."
other Patient
worker'sis
will:protected
a. show b. of
assessment
Providing
Afterpatient.
improved
the third-party
formulating
use b. of the players
language.
assess nursing b.with
the patient accesson
diagnoses
demonstrate
based toimproved
for apatient's
datanew medical
patient,
collected what
socialfrom records
skills. isc.
all c. Facilitating
a become
nurse's
sources. c.next
more
validate thethea.
action?
movement ofin
Designingimpression
independent
worker's a decision
patient's
interventions medical
to include
making.
by contacting chiatric
d. in the
select
the Mental
plan
and of
patient's Health
care
participateb. Nursing
significant one information
Determining
inother. group the
chiatric goals
activity to and
Mental the
per day.
Health
