Chapter 9. The Nursing Process in
Psychiatric/Mental Health Nursing
Which data-gathering technique is employed during the assessment phase of the nursing process?
A. Asking the client to rate mood after administering an antidepressant
B. Asking the client to verbalize understanding of previously explained unit rules
C. Asking the client to describe any thoughts of self-harm
D. Asking the client if the group on assertiveness skills was helpful - Answers-ANS: C
The nurse should ask the client to describe any thoughts of self-harm during the assessment phase of
the nursing process. Assessment involves collecting and analyzing data about the client that may include
the following dimensions: physical, psychological, sociocultural, spiritual, cognitive, developmental,
economic, lifestyle, and functional abilities. The other three options are employed during the evaluation
phase of the nursing process.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need:
Safe and Effective Care Environment
Which statement is most accurate regarding the assessment of clients diagnosed with psychiatric
problems?
A. Medical history is of little significance and can be eliminated from the nursing assessment.
B. Assessment provides a holistic view of the client, including biopsychosocial aspects.
C. Comprehensive assessments can be performed only by advanced practice nurses.
D. Psychosocial evaluations are gained by subjective reports rather than objective observations. -
Answers-ANS: B
,The assessment of clients diagnosed with psychiatric problems should provide a holistic view of the
client. A thorough assessment involves collecting and analyzing data from the client, significant others,
and health-care providers that may include the following dimensions: physical, psychological,
sociocultural, spiritual, cognitive, developmental, economic, lifestyle, and functional abilities.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need:
Safe and Effective Care Environment
Which nursing diagnosis should a nurse identify as being correctly formulated?
A. Schizophrenia R/T biochemical alterations AEB altered thought
B. Self-care deficit: hygiene R/T altered thought as AEB disheveled appearance
C. Depressed mood R/T multiple life stressors
D. Developmental disability R/T early-onset schizophrenia AEB hallucinations - Answers-ANS: B
The nurse should determine that the correctly written diagnosis would be Self-care deficit: hygiene R/T
altered thought AEB disheveled appearance. The nursing diagnosis should describe the unhealthy
response (inference), the contributing factors, and the data that support the inference.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Analysis | Client Need:
Psychosocial Integrity
Which expected client outcome should a nurse identify as being correctly formulated?
A. Client will feel happier by discharge.
B. Client will demonstrate two relaxation techniques.
C. Client will verbalize triggers to anger by end of session.
D. Client will initiate interaction with one peer during free time within 2 days. - Answers-ANS: D
The statement "Client will initiate interaction with one peer during free time within 2 days" is an
example of a correctly formulated expected outcome. Outcomes should be measurable, realistic, client-
focused goals that include a time frame. Appropriate nursing interventions are guided by client
outcomes.
, KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need:
Psychosocial Integrity
Which statement regarding nursing interventions should a nurse identify as accurate?
A. Nursing interventions are independent from the treatment team's goals.
B. Nursing interventions are directed solely by written physician orders.
C. Nursing interventions occur independently but in concert with overall treatment team goals.
D. Nursing interventions are standardized by policies and procedures. - Answers-ANS: C
The nurse should understand that nursing interventions occur independently but in concert with overall
treatment goals. Nursing interventions should be developed and implemented in collaboration with
other health-care professionals involved in the client's care.
KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Implementation | Client
Need: Safe and Effective Care Environment
Within the nurse's scope of practice, which function is exclusive to the advance practice psychiatric
nurse?
A. Teaching about the side effects of neuroleptic medications
B. Using psychotherapy to improve mental health status
C. Using milieu therapy to structure a therapeutic environment
D. Providing case management to coordinate continuity of health services - Answers-ANS: B
The advanced practice psychiatric nurse is authorized to use psychotherapy to improve mental health.
This includes individual, couples, group, and family psychotherapy. It is within the scope of practice of a
registered psychiatric mental health nurse generalist to provide education, case management, and
milieu therapy.
KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Implementation | Client
Need: Safe and Effective Care Environment
Psychiatric/Mental Health Nursing
Which data-gathering technique is employed during the assessment phase of the nursing process?
A. Asking the client to rate mood after administering an antidepressant
B. Asking the client to verbalize understanding of previously explained unit rules
C. Asking the client to describe any thoughts of self-harm
D. Asking the client if the group on assertiveness skills was helpful - Answers-ANS: C
The nurse should ask the client to describe any thoughts of self-harm during the assessment phase of
the nursing process. Assessment involves collecting and analyzing data about the client that may include
the following dimensions: physical, psychological, sociocultural, spiritual, cognitive, developmental,
economic, lifestyle, and functional abilities. The other three options are employed during the evaluation
phase of the nursing process.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need:
Safe and Effective Care Environment
Which statement is most accurate regarding the assessment of clients diagnosed with psychiatric
problems?
A. Medical history is of little significance and can be eliminated from the nursing assessment.
B. Assessment provides a holistic view of the client, including biopsychosocial aspects.
C. Comprehensive assessments can be performed only by advanced practice nurses.
D. Psychosocial evaluations are gained by subjective reports rather than objective observations. -
Answers-ANS: B
,The assessment of clients diagnosed with psychiatric problems should provide a holistic view of the
client. A thorough assessment involves collecting and analyzing data from the client, significant others,
and health-care providers that may include the following dimensions: physical, psychological,
sociocultural, spiritual, cognitive, developmental, economic, lifestyle, and functional abilities.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need:
Safe and Effective Care Environment
Which nursing diagnosis should a nurse identify as being correctly formulated?
A. Schizophrenia R/T biochemical alterations AEB altered thought
B. Self-care deficit: hygiene R/T altered thought as AEB disheveled appearance
C. Depressed mood R/T multiple life stressors
D. Developmental disability R/T early-onset schizophrenia AEB hallucinations - Answers-ANS: B
The nurse should determine that the correctly written diagnosis would be Self-care deficit: hygiene R/T
altered thought AEB disheveled appearance. The nursing diagnosis should describe the unhealthy
response (inference), the contributing factors, and the data that support the inference.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Analysis | Client Need:
Psychosocial Integrity
Which expected client outcome should a nurse identify as being correctly formulated?
A. Client will feel happier by discharge.
B. Client will demonstrate two relaxation techniques.
C. Client will verbalize triggers to anger by end of session.
D. Client will initiate interaction with one peer during free time within 2 days. - Answers-ANS: D
The statement "Client will initiate interaction with one peer during free time within 2 days" is an
example of a correctly formulated expected outcome. Outcomes should be measurable, realistic, client-
focused goals that include a time frame. Appropriate nursing interventions are guided by client
outcomes.
, KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need:
Psychosocial Integrity
Which statement regarding nursing interventions should a nurse identify as accurate?
A. Nursing interventions are independent from the treatment team's goals.
B. Nursing interventions are directed solely by written physician orders.
C. Nursing interventions occur independently but in concert with overall treatment team goals.
D. Nursing interventions are standardized by policies and procedures. - Answers-ANS: C
The nurse should understand that nursing interventions occur independently but in concert with overall
treatment goals. Nursing interventions should be developed and implemented in collaboration with
other health-care professionals involved in the client's care.
KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Implementation | Client
Need: Safe and Effective Care Environment
Within the nurse's scope of practice, which function is exclusive to the advance practice psychiatric
nurse?
A. Teaching about the side effects of neuroleptic medications
B. Using psychotherapy to improve mental health status
C. Using milieu therapy to structure a therapeutic environment
D. Providing case management to coordinate continuity of health services - Answers-ANS: B
The advanced practice psychiatric nurse is authorized to use psychotherapy to improve mental health.
This includes individual, couples, group, and family psychotherapy. It is within the scope of practice of a
registered psychiatric mental health nurse generalist to provide education, case management, and
milieu therapy.
KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Implementation | Client
Need: Safe and Effective Care Environment
