Chapter 11: The Psychiatric-Mental Health
Nursing Process
A client is admitted to the psychiatric unit and states, "I am president of the largest corporation
in the world. Everyone comes to me for advice." The nurse knows the client is exhibiting what?
a) Loose associations
b) Delusion
c) Thought broadcasting
d) Flight of ideas - ANS-b) Delusion
\A client is showing no facial expression when engaging in a game with peers during an outing
at a park. The nurse uses which term when documenting the client's affect?
a) Restricted affect
b) Flat affect
c) Absent affect
d) Broad affect - ANS-b) Flat affect
\A client reported to the nurse that on the client's way to the clinic, a police officer in a patrol car
turned on the car's lights and pulled the client over. When asked what the client did next, the
client stated, "I pulled over, of course." Which was the nurse trying to assess?
a) The client's concentration
b) The client's judgment
c) The client's insight
d) The client's self-concept - ANS-b) The client's judgment
\A client states, "I don't want to eat anything because I am afraid that my food is poisoned."
Which intervention is best for the nurse to perform to encourage the client to eat?
a) Ask the client about favorite foods to add for meals.
b) Encourage the client to help with meal preparation.
c) Tell the client to take vitamins on a daily basis.
d) Discuss the importance of proper nutrition with the client. - ANS-b) Encourage the client to
help with meal preparation.
\A client with a history of schizophrenia states "I am the ruler of a magical land." When the nurse
replies by stating who and where the client is, which interview behavior is the nurse using?
a) presenting reality
b) restating
c) giving recognition
d) focusing - ANS-a) presenting reality
, \A client's frequent night awakenings, early morning rising, and daytime drowsiness have
prompted the nurse to add a diagnosis of "disturbed sleep pattern" to the client's plan of care.
What information should immediately follow this diagnosis?
a) Previous attempts at alleviating the diagnosis
b) The evidence supporting the diagnosis
c) The DSM-IV-TR diagnosis that corresponds to the nursing diagnosis
d) The client's preferred intervention for the diagnosis - ANS-b) The evidence supporting the
diagnosis
\A client's nursing diagnosis of "risk for self-directed violence" has been identified because of
her recent history of cutting and self-mutilation. Which of the following expected outcomes is
most appropriate for this client's plan of care during inpatient treatment?
a) "Staff will observe the client for signs of self-mutilation."
b) "The client will demonstrate better coping skills."
c) "The client will demonstrate resolution of her psychiatric diagnosis."
d) "The client will refrain from cutting or self-mutilation." - ANS-d) "The client will refrain from
cutting or self-mutilation."
\A delusion represents a problem in which of the following areas?
a) Memory
b) Orientation
c) Thinking
d) Motivation - ANS-c) Thinking
\A nurse awaits the arrival of a client who is being transferred from a nursing home. The client
has a history of schizophrenia and has been behaving bizarrely. The nurse begins preparing the
plan of care by outlining expected outcomes. The nurse's actions are which of the following?
a) Consistent with the nursing process, because the goals generally will be applicable to all
clients with schizophrenia
b) Inconsistent with the nursing process, because assessment always comes first
c) Consistent with the nursing process, because goals should be identified before interventions
d) Inconsistent with the nursing process, because the nurse should establish goals with the
client - ANS-b) Inconsistent with the nursing process, because assessment always comes first
\A nurse can best assess a client's ability to use abstract thinking by asking the client which
question?
a) "What do I mean when I say, 'Don't sweat the small stuff?'"
b) "Can you begin with the number 100 and subtract 7, and then subtract 7 again?"
c) "What are you going to do next time you hear voices?"
d) "What would you do if you found a wallet containing $100 on the sidewalk?" - ANS-a) "What
do I mean when I say, 'Don't sweat the small stuff?'"
\A nurse develops a plan of care for a client with an eating disorder. The plan includes
developing a contract with the client to modify behavior. What is the next step?
Nursing Process
A client is admitted to the psychiatric unit and states, "I am president of the largest corporation
in the world. Everyone comes to me for advice." The nurse knows the client is exhibiting what?
a) Loose associations
b) Delusion
c) Thought broadcasting
d) Flight of ideas - ANS-b) Delusion
\A client is showing no facial expression when engaging in a game with peers during an outing
at a park. The nurse uses which term when documenting the client's affect?
a) Restricted affect
b) Flat affect
c) Absent affect
d) Broad affect - ANS-b) Flat affect
\A client reported to the nurse that on the client's way to the clinic, a police officer in a patrol car
turned on the car's lights and pulled the client over. When asked what the client did next, the
client stated, "I pulled over, of course." Which was the nurse trying to assess?
a) The client's concentration
b) The client's judgment
c) The client's insight
d) The client's self-concept - ANS-b) The client's judgment
\A client states, "I don't want to eat anything because I am afraid that my food is poisoned."
Which intervention is best for the nurse to perform to encourage the client to eat?
a) Ask the client about favorite foods to add for meals.
b) Encourage the client to help with meal preparation.
c) Tell the client to take vitamins on a daily basis.
d) Discuss the importance of proper nutrition with the client. - ANS-b) Encourage the client to
help with meal preparation.
\A client with a history of schizophrenia states "I am the ruler of a magical land." When the nurse
replies by stating who and where the client is, which interview behavior is the nurse using?
a) presenting reality
b) restating
c) giving recognition
d) focusing - ANS-a) presenting reality
, \A client's frequent night awakenings, early morning rising, and daytime drowsiness have
prompted the nurse to add a diagnosis of "disturbed sleep pattern" to the client's plan of care.
What information should immediately follow this diagnosis?
a) Previous attempts at alleviating the diagnosis
b) The evidence supporting the diagnosis
c) The DSM-IV-TR diagnosis that corresponds to the nursing diagnosis
d) The client's preferred intervention for the diagnosis - ANS-b) The evidence supporting the
diagnosis
\A client's nursing diagnosis of "risk for self-directed violence" has been identified because of
her recent history of cutting and self-mutilation. Which of the following expected outcomes is
most appropriate for this client's plan of care during inpatient treatment?
a) "Staff will observe the client for signs of self-mutilation."
b) "The client will demonstrate better coping skills."
c) "The client will demonstrate resolution of her psychiatric diagnosis."
d) "The client will refrain from cutting or self-mutilation." - ANS-d) "The client will refrain from
cutting or self-mutilation."
\A delusion represents a problem in which of the following areas?
a) Memory
b) Orientation
c) Thinking
d) Motivation - ANS-c) Thinking
\A nurse awaits the arrival of a client who is being transferred from a nursing home. The client
has a history of schizophrenia and has been behaving bizarrely. The nurse begins preparing the
plan of care by outlining expected outcomes. The nurse's actions are which of the following?
a) Consistent with the nursing process, because the goals generally will be applicable to all
clients with schizophrenia
b) Inconsistent with the nursing process, because assessment always comes first
c) Consistent with the nursing process, because goals should be identified before interventions
d) Inconsistent with the nursing process, because the nurse should establish goals with the
client - ANS-b) Inconsistent with the nursing process, because assessment always comes first
\A nurse can best assess a client's ability to use abstract thinking by asking the client which
question?
a) "What do I mean when I say, 'Don't sweat the small stuff?'"
b) "Can you begin with the number 100 and subtract 7, and then subtract 7 again?"
c) "What are you going to do next time you hear voices?"
d) "What would you do if you found a wallet containing $100 on the sidewalk?" - ANS-a) "What
do I mean when I say, 'Don't sweat the small stuff?'"
\A nurse develops a plan of care for a client with an eating disorder. The plan includes
developing a contract with the client to modify behavior. What is the next step?
