Chapteri01:iMe,iMeds,iMilieu
Steele:iKeltner’siPsychiatriciNursing,i9thiEdition
MULTIPLEiCHOICE
1. Ainewlyilicensedinurseiasksiainursingirecruiteriforiaidescriptioniofinursingipracticeiinith
eipsychiatricisetting.iWhatiisitheinurseirecruiter‘sibestiresponse?
a. ―Theinurseiprimarilyiservesiiniaisupportiveiroleitoimembersiofitheihealthicare
deliveryiteam.‖
b. ―Theimultidisciplinaryiapproachieliminatesitheineeditoiclearlyidefineithe
responsibilitiesiofinursingiinisuchiaisetting.‖
c. ―Nursingiactionsiareiidentifiedibyitheiinstitutionithatidistinguishesinursingifrom
otherimentalihealthiprofessions.‖
d. ―Nursingioffersiuniqueicontributionsitoitheipsychotherapeuticimanagementiof
psychiatricipatients.‖
ANS:i D
Professionaliroleioverlapicannotibeidenied;ihowever,inursingiisiuniqueiiniitsifocusioniandia
pplicationiofipsychotherapeuticimanagement.iNeitheritheifacilityinoritheimultidisciplinaryitea
midefineitheiprofessionaliresponsibilitiesiofiitsimembersibutiratheriutilizesitheiriuniqueiskill
sitoiprovideiholisticicare.iIdeally,ialliteamimembersisupportieachiotheriandihaveifunctionsiw
ithinitheiteam.
DIF: Cognitiveilevel:iAnalyzing
TOP:i Nursingiprocess:iImplementationiMSC:i ClientiNeeds:iSafe,iEffectivei
CareiEnvironment
2. Whichicomponentiofitheinursingiprocessiwillitheinurseifocusiuponitoiaddressith
eiresponsibilityitoimatchiindividualipatientineedsiwithiappropriateiservices?
a. Planning
b. Evaluation
c. Assessment
d. Implementation
ANS:i C
Properiassessmentiisicriticaliforibeingiableitoidetermineitheiappropriateileveliofiservicesithat
iwilliprovideioptimalicareiwhileiconsideringipatientiinputiandiatitheilowesticost.iPlanningian
diimplementationiutilizesitheiassessmentidataitoiidentifyiandiexecuteiactionsi(treatmentiplan)
ithatiwilliprovideiappropriateicare.iEvaluationivalidatesitheieffectivenessiofitheitreatmentipla
n.
DIF: Cognitiveilevel:iApplying
TOP:i Nursingiprocess:iAssessmentiMSC:i ClientiNeeds:iSafe,iEffectivei
CareiEnvironment
3. Aniadultidiagnosediwithiparanoidischizophreniaifrequentlyiexperiencesiauditoryihallucin
ationsiandiwalksiaboutitheiunit,imuttering.iWhichinursingiactionidemonstratesitheinurse‘s
iunderstandingiofieffectiveipsychotherapeuticimanagementiofithisiclient?
a. Discussingitheidiseaseiprocessiofischizophreniaiwithitheiclientianditheiridomestic
partner
b. Minimizingicontactibetweenithisipatientiandiotheripatientsitoiassureiaistress-free
milieu
c. AdministeringiPRNimedicationiwhenifirstiobservingitheievidenceithatitheiclient
, mayibeihallucinating
d. Independentlyideterminingithatibehaviorimodificationiisiappropriateitoidecrease
theiclient‘siparanoidithoughts
ANS:i A
Aniunderstandingiofipsychopathologyiisitheifoundationioniwhichitheithreeicomponentsiofip
sychotherapeuticimanagementirest;iitifacilitatesitherapeuticicommunicationiandiprovidesiaiba
sisiforiunderstandingipsychopharmacologyiandimilieuimanagement.iMinimizingicontactibet
weenitheipatientiandiothersiandiadministeringiPRNimedicationiindiscriminatelyiareinonther
apeuticiinterventions.iUsingibehaviorimodificationitoidecreaseitheifrequencyiofihallucinatio
nsiwouldineeditoibeiincorporatediintoitheiplanioficareibyitheicareiteam.
DIF: Cognitiveilevel:iApplying
TOP:i Nursingiprocess:iImplementationiMSC:i ClientiNeeds:iSafe,iEffectivei
CareiEnvironment
4. Aniadultidiagnosediwithichronicidepressioniisihospitalizediafteriaisuicideiattempt.iWhic
hiinterventioniisicriticaliiniassuringilong-
term,ieffectiveiclienticareiasidescribedibyipsychotherapeuticimanagement?
a. Involvementiinigroupitherapies
b. Focusioficloseisupervisionibyitheiunitistaff
c. Maintainingieffectiveicommunicationiwithisupportisystem
d. Frequentlyischeduledione-on-oneitimeiwithinursingistaff
ANS:i D
Aicriticalielementiofipsychotherapeuticimanagementiisitheipresenceiofiaitherapeutic
nurse-patientirelationship.iOne-on-
oneitimeiwithinursingistaffiwillihelpiiniestablishingithisiconnection.iWhileitheiotherioptionsi
areiappropriateiandiclienticentered,itheinurse-clientirelationiisicriticaliinitheilong-
termideliveryiofiqualityieffectiveicareitoithisiclient.
DIF: Cognitiveilevel:iApplying
TOP:i Nursingiprocess:iImplementationiMSC:i ClientiNeeds:iPsychosocialiIn
tegrity
5. Aipatient‘sihaloperidolidosageiwasireducedi2iweeksiagoitoidecreaseisideieffects.iWhati
assessmentiquestionidemonstratesitheinurse‘siunderstandingiofitheiresultingineedsiofith
eiclient?
a. ―Williyouihaveianyidifficultyigettingiyouriprescriptionirefilled?‖
b. ―Haveiyouibeguniexperiencingianyiformsiofihallucinations?‖
c. ―Whatidoiyouiexpectiwillioccurisinceitheidosageihasibeenireduced?‖
d. ―WhaticaniIidoitoihelpiyouimanageithisireductioniinihaloperidolitherapy?‖
ANS:i B
Itiwillibeinecessaryiforitheinurseitoiassessiforiexacerbationiofitheipatient‘sisymptomsiofipsy
chosisiasiwelliasiforiailesseningiofisideieffects.iDosageidecreaseimightileaditoitheireturniori
worseningiofipositiveisymptomsisuchiasihallucinationsiandidelusions,iandinegativeisympto
msisuchiasibluntediaffect,isocialiwithdrawal,iandipoorigrooming.iWhileitheiotherioptionsim
ayibeiappropriateiassessmentiquestions,itheyiareinotidirectediatitheicurrentineedsiofitheiclient
iwhichiisitheiidentificationiofiemergingipsychoticibehaviors.
DIF: Cognitiveilevel:iAnalyzing
TOP:i Nursingiprocess:iAssessmentiMSC:i ClientiNeeds:iPhysiologiciInt
egrity
,6. Whichistatementiformsitheifoundationiuponiwhichiainurseishouldibaseitheiimplementationio
fipsychotherapeuticimanagementitoitheicareiofiaipatientiwithimentaliillness?
a. Theinurse‘siroleiiniclienticareiisisupportedibyitheimultidisciplinaryiteam.
b. Omittingianyioneicomponentiwillicompromiseitheieffectivenessiofitheitreatment.
c. Theimostiimportantielementiofipsychotherapeuticimanagementiisidrugitherapy.
d. Aitherapeuticinurse-patientirelationshipiisitheimostiimportantiaspectiofitreatment.
ANS:i B
Whenioneielementiisimissing,itreatmentiisiusuallyicompromised.iNoisingleielementiisimore
iimportantithanitheiothers;ihowever,ipatients‘ineedsigovernitheiapplicationiofitheicomponen
tsiandipermitijudiciousiuse.iTheiremainingioptionsiidentifyicomponentsiofitheipsychotherap
euticimanagementiprocess.
DIF: Cognitiveilevel:iAnalyzing
TOP:i Nursingiprocess:iAnalysisiMSC:i ClientiNeeds:iSafe,iEffectivei
CareiEnvironment
7. Whichistatementimostiaccuratelyidescribesiainurse‘siroleiregardingipsychopharmacology?
a. ―YouiwillineeditoifrequentlyimakeidecisionsiregardingitheiadministrationiofiPRN
medicationsitoihelpitheiclientimanageianger.‖
b. ―It‘siainursingiresponsibilityitoiadjustiaimedicationidoseitoiassureieffectiveipatientir
esponses.‖
c. ―Nursesiadministersimedicationsiwhileievaluatingidrugieffectivenessiisiaimedicalire
sponsibility.‖
d. ―Toibestiassureiappropriateiresponse,iaipatient‘siquestionsiaboutidrugitherapyishou
ldibeireferreditoitheipsychiatrist.‖
ANS:i A
NursingiassessmentiandianalysisiofidataimightisuggestitheineediforiPRNimedicationiasipatie
ntianxietyiincreasesioripsychoticisymptomsibecomeimoreiacute.iTheinurseiisitheihealthiteam
imemberiwhoimakesithisidetermination.iNursesiareiresponsibleiforimonitoringidrugieffective
nessiasiwelliasiadministeringimedication.iNursesishouldiassumeiresponsibilityiforiteachingip
atientsiaboutitheisideieffectsiofimedications.iNursesicannotialteriprescribedidosagesiofimedic
ationsiunlessitheyihaveiprescriptiveiprivileges.
DIF: Cognitiveilevel:iAnalyzing
TOP:i Nursingiprocess:iAnalysisiMSC:i ClientiNeeds:iSafe,iEffectivei
CareiEnvironment
8. Wheniconsideringienvironmentaliaspectsiofimilieuimanagement,iwhichiinterventionihasith
eihighestipriorityiforiaiclientiadmittediafteriaifailedisuicideiattempt?
a. Sendingitheiclient‘sinewimedicationiprescriptionsitoitheipharmacy
b. Assigningiaistaffimemberitoione-on-oneiobservationiofitheiclient
c. Orientingitheiclientitoitheimilieu‘sipubliciandiprivateispaces
d. Havingiallipotentiallyidangerousiitemsiremovedifromitheiclient‘sibelongings
ANS:i B
Milieuimanagementiprovidesiaiproactiveiapproachitoicare.iSafetyioverridesialliotheridimens
ionsiofitheimilieu.iInitiationiofisuicideiprecautionsiareitheipriorityiforithisiclient.iAllitheirem
ainingioptionsiareiappropriateibutinoneiprotectitheiclientifromitheiriskiofianotheriattemptito
iself-harmiasieffectivelyiasione-on-oneiobservationiasipartiofisuicideiprecautions.
DIF: Cognitiveilevel:iAnalyzing TOP:i Nursingiprocess:iImplementation
, MSC:i ClientiNeeds:iSafe,iEffectiveiCareiEnvironment
9. Theiimplementationiofiwhichiunitipolicyidirectediatimilieuibalanceiwouldireflectiaineedif
orireconsiderationionitheipartiofitheitreatmentiteam?
a. Alliclientsiwillireceiveiverbaliandiwritteniinformationiexplainingiunitirules.
b. Uniticlientsiwilliengageiinialliunitiactivitiesitoiassureiinteractioniwithibothistaffia
ndiothericlients.
c. Alliclientsiwillibeiuniformlyiexpecteditoipresentithemselvesiiniainonviolentiman
neritoibothistaffiandiothericlients.
d. Atitimesiofiunitistress,iclientiwillireturnitoitheirirooms.
ANS:i B
Theisituationidescribedisuggestsiaimilieuiiniwhichipatientsihaveinoitimeiforiplanneditherape
uticiencountersiwithistaff;ihence,iitiisiaimilieuilackingibalance.iTheiremainingioptionsiaddres
siunitinorms,ilimitisetting,iandienvironmentalimodificationsithatiareireasonableiandiwillicontri
buteitoiaitherapeuticimilieu.
DIF: Cognitiveilevel:iEvaluating
TOP:i Nursingiprocess:iEvaluationiMSC:i ClientiNeeds:iSafe,iEffectivei
CareiEnvironment
10. Whichiinterventionishoulditheinurseiimplementiwhenifocusingionicommunicatin
githerapeuticallyiwithiaiclient?
a. Explainingitoitheiclientiwhyitheyiwillineeditoiaskiforiairazor
b. Providingitheiclientiwithioptionsitoihelpiachieveismokingicessation
c. Encouragingitheiclientitoiidentifyipersonalistressors
d. Assuringitheiclientithatitheyicanireceiveitelephoneicallionitheiunititelephone
ANS:i C
Ainurseiusesitherapeuticicommunicationitechniquesiasipartiofitheitherapeuticinurse-
patientirelationship.iAniexampleiofisuchicommunicationiisiprovidingitheiclientiwithianioppo
rtunityitoisafelyiidentifyipersonalistressors.iTheiremainingioptionsiaddressisafety,ibalance,ian
dinormsiassociatediwithitheiricare.
DIF: Cognitiveilevel:iApplying
TOP:i Nursingiprocess:iImplementationiMSC:i ClientiNeeds:iPsychosocialiIn
tegrity
11. Duringitheiriskiassessmentiphaseioficareiforiaipsychiatricipatient,iwhatiisitheinurse‘s
Primary igoal?
a. Makingianiinitialiassessment
b. Confirmingitheipatient‘siproblem
c. Assessingipotentialidangerousnessitoiselfioriothers
d. Determiningitheileveliofisupervisionineedediforitheipatient
ANS:i C
Riskiassessmentiinvolvesilookingiatidangerousnessitoiselfioriothers,itheidegreeiofidisability
,iandiwhetheriorinotitheiindividualiisiacutelyipsychoticitoidetermineitheifeasibilityioficomm
unity-basedicareiversusihospital-
basedicare.iRiskiassessmentiusuallyifollowsitheiinitialiassessment.iConfirmationiofitheipatie
nt‘siproblemiisinotipartiofitheiriskiassessmentiprotocol.iArrangingientryiintoitheimentaliheal
thisystemiwillifollowiriskiassessmentiifitheipatientiisiassessediasineedingiservice.
DIF: Cognitiveilevel:iApplying TOP:i Nursingiprocess:iAssessment
Steele:iKeltner’siPsychiatriciNursing,i9thiEdition
MULTIPLEiCHOICE
1. Ainewlyilicensedinurseiasksiainursingirecruiteriforiaidescriptioniofinursingipracticeiinith
eipsychiatricisetting.iWhatiisitheinurseirecruiter‘sibestiresponse?
a. ―Theinurseiprimarilyiservesiiniaisupportiveiroleitoimembersiofitheihealthicare
deliveryiteam.‖
b. ―Theimultidisciplinaryiapproachieliminatesitheineeditoiclearlyidefineithe
responsibilitiesiofinursingiinisuchiaisetting.‖
c. ―Nursingiactionsiareiidentifiedibyitheiinstitutionithatidistinguishesinursingifrom
otherimentalihealthiprofessions.‖
d. ―Nursingioffersiuniqueicontributionsitoitheipsychotherapeuticimanagementiof
psychiatricipatients.‖
ANS:i D
Professionaliroleioverlapicannotibeidenied;ihowever,inursingiisiuniqueiiniitsifocusioniandia
pplicationiofipsychotherapeuticimanagement.iNeitheritheifacilityinoritheimultidisciplinaryitea
midefineitheiprofessionaliresponsibilitiesiofiitsimembersibutiratheriutilizesitheiriuniqueiskill
sitoiprovideiholisticicare.iIdeally,ialliteamimembersisupportieachiotheriandihaveifunctionsiw
ithinitheiteam.
DIF: Cognitiveilevel:iAnalyzing
TOP:i Nursingiprocess:iImplementationiMSC:i ClientiNeeds:iSafe,iEffectivei
CareiEnvironment
2. Whichicomponentiofitheinursingiprocessiwillitheinurseifocusiuponitoiaddressith
eiresponsibilityitoimatchiindividualipatientineedsiwithiappropriateiservices?
a. Planning
b. Evaluation
c. Assessment
d. Implementation
ANS:i C
Properiassessmentiisicriticaliforibeingiableitoidetermineitheiappropriateileveliofiservicesithat
iwilliprovideioptimalicareiwhileiconsideringipatientiinputiandiatitheilowesticost.iPlanningian
diimplementationiutilizesitheiassessmentidataitoiidentifyiandiexecuteiactionsi(treatmentiplan)
ithatiwilliprovideiappropriateicare.iEvaluationivalidatesitheieffectivenessiofitheitreatmentipla
n.
DIF: Cognitiveilevel:iApplying
TOP:i Nursingiprocess:iAssessmentiMSC:i ClientiNeeds:iSafe,iEffectivei
CareiEnvironment
3. Aniadultidiagnosediwithiparanoidischizophreniaifrequentlyiexperiencesiauditoryihallucin
ationsiandiwalksiaboutitheiunit,imuttering.iWhichinursingiactionidemonstratesitheinurse‘s
iunderstandingiofieffectiveipsychotherapeuticimanagementiofithisiclient?
a. Discussingitheidiseaseiprocessiofischizophreniaiwithitheiclientianditheiridomestic
partner
b. Minimizingicontactibetweenithisipatientiandiotheripatientsitoiassureiaistress-free
milieu
c. AdministeringiPRNimedicationiwhenifirstiobservingitheievidenceithatitheiclient
, mayibeihallucinating
d. Independentlyideterminingithatibehaviorimodificationiisiappropriateitoidecrease
theiclient‘siparanoidithoughts
ANS:i A
Aniunderstandingiofipsychopathologyiisitheifoundationioniwhichitheithreeicomponentsiofip
sychotherapeuticimanagementirest;iitifacilitatesitherapeuticicommunicationiandiprovidesiaiba
sisiforiunderstandingipsychopharmacologyiandimilieuimanagement.iMinimizingicontactibet
weenitheipatientiandiothersiandiadministeringiPRNimedicationiindiscriminatelyiareinonther
apeuticiinterventions.iUsingibehaviorimodificationitoidecreaseitheifrequencyiofihallucinatio
nsiwouldineeditoibeiincorporatediintoitheiplanioficareibyitheicareiteam.
DIF: Cognitiveilevel:iApplying
TOP:i Nursingiprocess:iImplementationiMSC:i ClientiNeeds:iSafe,iEffectivei
CareiEnvironment
4. Aniadultidiagnosediwithichronicidepressioniisihospitalizediafteriaisuicideiattempt.iWhic
hiinterventioniisicriticaliiniassuringilong-
term,ieffectiveiclienticareiasidescribedibyipsychotherapeuticimanagement?
a. Involvementiinigroupitherapies
b. Focusioficloseisupervisionibyitheiunitistaff
c. Maintainingieffectiveicommunicationiwithisupportisystem
d. Frequentlyischeduledione-on-oneitimeiwithinursingistaff
ANS:i D
Aicriticalielementiofipsychotherapeuticimanagementiisitheipresenceiofiaitherapeutic
nurse-patientirelationship.iOne-on-
oneitimeiwithinursingistaffiwillihelpiiniestablishingithisiconnection.iWhileitheiotherioptionsi
areiappropriateiandiclienticentered,itheinurse-clientirelationiisicriticaliinitheilong-
termideliveryiofiqualityieffectiveicareitoithisiclient.
DIF: Cognitiveilevel:iApplying
TOP:i Nursingiprocess:iImplementationiMSC:i ClientiNeeds:iPsychosocialiIn
tegrity
5. Aipatient‘sihaloperidolidosageiwasireducedi2iweeksiagoitoidecreaseisideieffects.iWhati
assessmentiquestionidemonstratesitheinurse‘siunderstandingiofitheiresultingineedsiofith
eiclient?
a. ―Williyouihaveianyidifficultyigettingiyouriprescriptionirefilled?‖
b. ―Haveiyouibeguniexperiencingianyiformsiofihallucinations?‖
c. ―Whatidoiyouiexpectiwillioccurisinceitheidosageihasibeenireduced?‖
d. ―WhaticaniIidoitoihelpiyouimanageithisireductioniinihaloperidolitherapy?‖
ANS:i B
Itiwillibeinecessaryiforitheinurseitoiassessiforiexacerbationiofitheipatient‘sisymptomsiofipsy
chosisiasiwelliasiforiailesseningiofisideieffects.iDosageidecreaseimightileaditoitheireturniori
worseningiofipositiveisymptomsisuchiasihallucinationsiandidelusions,iandinegativeisympto
msisuchiasibluntediaffect,isocialiwithdrawal,iandipoorigrooming.iWhileitheiotherioptionsim
ayibeiappropriateiassessmentiquestions,itheyiareinotidirectediatitheicurrentineedsiofitheiclient
iwhichiisitheiidentificationiofiemergingipsychoticibehaviors.
DIF: Cognitiveilevel:iAnalyzing
TOP:i Nursingiprocess:iAssessmentiMSC:i ClientiNeeds:iPhysiologiciInt
egrity
,6. Whichistatementiformsitheifoundationiuponiwhichiainurseishouldibaseitheiimplementationio
fipsychotherapeuticimanagementitoitheicareiofiaipatientiwithimentaliillness?
a. Theinurse‘siroleiiniclienticareiisisupportedibyitheimultidisciplinaryiteam.
b. Omittingianyioneicomponentiwillicompromiseitheieffectivenessiofitheitreatment.
c. Theimostiimportantielementiofipsychotherapeuticimanagementiisidrugitherapy.
d. Aitherapeuticinurse-patientirelationshipiisitheimostiimportantiaspectiofitreatment.
ANS:i B
Whenioneielementiisimissing,itreatmentiisiusuallyicompromised.iNoisingleielementiisimore
iimportantithanitheiothers;ihowever,ipatients‘ineedsigovernitheiapplicationiofitheicomponen
tsiandipermitijudiciousiuse.iTheiremainingioptionsiidentifyicomponentsiofitheipsychotherap
euticimanagementiprocess.
DIF: Cognitiveilevel:iAnalyzing
TOP:i Nursingiprocess:iAnalysisiMSC:i ClientiNeeds:iSafe,iEffectivei
CareiEnvironment
7. Whichistatementimostiaccuratelyidescribesiainurse‘siroleiregardingipsychopharmacology?
a. ―YouiwillineeditoifrequentlyimakeidecisionsiregardingitheiadministrationiofiPRN
medicationsitoihelpitheiclientimanageianger.‖
b. ―It‘siainursingiresponsibilityitoiadjustiaimedicationidoseitoiassureieffectiveipatientir
esponses.‖
c. ―Nursesiadministersimedicationsiwhileievaluatingidrugieffectivenessiisiaimedicalire
sponsibility.‖
d. ―Toibestiassureiappropriateiresponse,iaipatient‘siquestionsiaboutidrugitherapyishou
ldibeireferreditoitheipsychiatrist.‖
ANS:i A
NursingiassessmentiandianalysisiofidataimightisuggestitheineediforiPRNimedicationiasipatie
ntianxietyiincreasesioripsychoticisymptomsibecomeimoreiacute.iTheinurseiisitheihealthiteam
imemberiwhoimakesithisidetermination.iNursesiareiresponsibleiforimonitoringidrugieffective
nessiasiwelliasiadministeringimedication.iNursesishouldiassumeiresponsibilityiforiteachingip
atientsiaboutitheisideieffectsiofimedications.iNursesicannotialteriprescribedidosagesiofimedic
ationsiunlessitheyihaveiprescriptiveiprivileges.
DIF: Cognitiveilevel:iAnalyzing
TOP:i Nursingiprocess:iAnalysisiMSC:i ClientiNeeds:iSafe,iEffectivei
CareiEnvironment
8. Wheniconsideringienvironmentaliaspectsiofimilieuimanagement,iwhichiinterventionihasith
eihighestipriorityiforiaiclientiadmittediafteriaifailedisuicideiattempt?
a. Sendingitheiclient‘sinewimedicationiprescriptionsitoitheipharmacy
b. Assigningiaistaffimemberitoione-on-oneiobservationiofitheiclient
c. Orientingitheiclientitoitheimilieu‘sipubliciandiprivateispaces
d. Havingiallipotentiallyidangerousiitemsiremovedifromitheiclient‘sibelongings
ANS:i B
Milieuimanagementiprovidesiaiproactiveiapproachitoicare.iSafetyioverridesialliotheridimens
ionsiofitheimilieu.iInitiationiofisuicideiprecautionsiareitheipriorityiforithisiclient.iAllitheirem
ainingioptionsiareiappropriateibutinoneiprotectitheiclientifromitheiriskiofianotheriattemptito
iself-harmiasieffectivelyiasione-on-oneiobservationiasipartiofisuicideiprecautions.
DIF: Cognitiveilevel:iAnalyzing TOP:i Nursingiprocess:iImplementation
, MSC:i ClientiNeeds:iSafe,iEffectiveiCareiEnvironment
9. Theiimplementationiofiwhichiunitipolicyidirectediatimilieuibalanceiwouldireflectiaineedif
orireconsiderationionitheipartiofitheitreatmentiteam?
a. Alliclientsiwillireceiveiverbaliandiwritteniinformationiexplainingiunitirules.
b. Uniticlientsiwilliengageiinialliunitiactivitiesitoiassureiinteractioniwithibothistaffia
ndiothericlients.
c. Alliclientsiwillibeiuniformlyiexpecteditoipresentithemselvesiiniainonviolentiman
neritoibothistaffiandiothericlients.
d. Atitimesiofiunitistress,iclientiwillireturnitoitheirirooms.
ANS:i B
Theisituationidescribedisuggestsiaimilieuiiniwhichipatientsihaveinoitimeiforiplanneditherape
uticiencountersiwithistaff;ihence,iitiisiaimilieuilackingibalance.iTheiremainingioptionsiaddres
siunitinorms,ilimitisetting,iandienvironmentalimodificationsithatiareireasonableiandiwillicontri
buteitoiaitherapeuticimilieu.
DIF: Cognitiveilevel:iEvaluating
TOP:i Nursingiprocess:iEvaluationiMSC:i ClientiNeeds:iSafe,iEffectivei
CareiEnvironment
10. Whichiinterventionishoulditheinurseiimplementiwhenifocusingionicommunicatin
githerapeuticallyiwithiaiclient?
a. Explainingitoitheiclientiwhyitheyiwillineeditoiaskiforiairazor
b. Providingitheiclientiwithioptionsitoihelpiachieveismokingicessation
c. Encouragingitheiclientitoiidentifyipersonalistressors
d. Assuringitheiclientithatitheyicanireceiveitelephoneicallionitheiunititelephone
ANS:i C
Ainurseiusesitherapeuticicommunicationitechniquesiasipartiofitheitherapeuticinurse-
patientirelationship.iAniexampleiofisuchicommunicationiisiprovidingitheiclientiwithianioppo
rtunityitoisafelyiidentifyipersonalistressors.iTheiremainingioptionsiaddressisafety,ibalance,ian
dinormsiassociatediwithitheiricare.
DIF: Cognitiveilevel:iApplying
TOP:i Nursingiprocess:iImplementationiMSC:i ClientiNeeds:iPsychosocialiIn
tegrity
11. Duringitheiriskiassessmentiphaseioficareiforiaipsychiatricipatient,iwhatiisitheinurse‘s
Primary igoal?
a. Makingianiinitialiassessment
b. Confirmingitheipatient‘siproblem
c. Assessingipotentialidangerousnessitoiselfioriothers
d. Determiningitheileveliofisupervisionineedediforitheipatient
ANS:i C
Riskiassessmentiinvolvesilookingiatidangerousnessitoiselfioriothers,itheidegreeiofidisability
,iandiwhetheriorinotitheiindividualiisiacutelyipsychoticitoidetermineitheifeasibilityioficomm
unity-basedicareiversusihospital-
basedicare.iRiskiassessmentiusuallyifollowsitheiinitialiassessment.iConfirmationiofitheipatie
nt‘siproblemiisinotipartiofitheiriskiassessmentiprotocol.iArrangingientryiintoitheimentaliheal
thisystemiwillifollowiriskiassessmentiifitheipatientiisiassessediasineedingiservice.
DIF: Cognitiveilevel:iApplying TOP:i Nursingiprocess:iAssessment
