10TH EDITION
• AUTHOR(S)SHEILA L. VIDEBECK
TEST BANK
UNIT 1 — CURRENT THEORIES & PRACTICE
1)
Reference: Ch. 1 — Foundations of Psychiatric–Mental Health
Nursing — Mental Health vs. Mental Illness / Assessment
Stem: A 28-year-old man admitted to an acute psychiatric unit
says, “I feel fine — I just can’t sleep.” He appears disheveled,
speaks rapidly, and reports racing thoughts. As the assigned
nurse, which initial nursing action best distinguishes mental
health variation from a mental disorder and prioritizes safety?
A. Schedule an immediate group activity to observe social
functioning.
B. Complete a focused mental status exam and assess risk for
,harm or escalation.
C. Provide psychoeducation about sleep hygiene and discharge
planning.
D. Ask the primary provider to transfer the patient to medical
services for further testing.
Correct answer: B
Rationale — Correct (B): A focused mental status exam (level of
consciousness, thought process, mood, judgment) and risk
assessment identify whether presentation reflects an acute
psychiatric disorder (e.g., mania, psychosis) and determine
immediate safety needs; this is the nurse’s priority and scope-
aligned initial action.
Rationale — Incorrect (A): Group activity may provide collateral
information later but is not an initial safety-prioritizing
assessment and may place others at risk if the patient is
unstable.
Rationale — Incorrect (C): Sleep hygiene is important but
premature before assessing for acute risk or underlying
psychiatric processes driving insomnia and rapid speech.
Rationale — Incorrect (D): Medical transfer may be needed
later if a medical cause is suspected, but first-line nursing action
is to assess mental status and risk to inform appropriate
referrals.
Teaching point: Always perform a focused MSE and risk
assessment first to guide immediate interventions.
,Citation: Videbeck, S. L. (2025). Psychiatric–Mental Health
Nursing (10th ed.). Ch. 1.
2)
Reference: Ch. 1 — Foundations of Psychiatric–Mental Health
Nursing — DSM & Diagnostic Labels
Stem: A nurse documents, “Client is manipulative and has
borderline personality disorder.” During handoff, a new nurse
asks why the term “manipulative” was used. Which response
best models therapeutic, nonjudgmental clinical documentation
and aligns with the DSM-informed approach?
A. “We document behaviors as observed and relate them to
functional impact rather than labeling intent.”
B. “Labels like ‘manipulative’ help the team quickly understand
the diagnosis and guide treatment.”
C. “It’s acceptable because the DSM lists manipulative
behaviors under personality disorders.”
D. “The charting is fine — this client’s behaviors are clearly
intentional.”
Correct answer: A
Rationale — Correct (A): Professional documentation prioritizes
objective, behavior-focused descriptions and functional impact;
DSM diagnostic criteria inform understanding but
documentation should avoid pejorative labels that imply intent
or moral judgment.
, Rationale — Incorrect (B): Labels oversimplify and risk stigma;
accurate care requires describing observable behavior and its
effects on functioning rather than derogatory shorthand.
Rationale — Incorrect (C): DSM describes patterns and criteria
but does not justify subjective, characterizing language;
documentation must remain objective.
Rationale — Incorrect (D): Asserting intent is speculative and
unprofessional; nursing documentation must describe observed
behavior and assessment findings.
Teaching point: Document observable behaviors and functional
impact; avoid pejorative labels.
Citation: Videbeck, S. L. (2025). Psychiatric–Mental Health
Nursing (10th ed.). Ch. 1.
3)
Reference: Ch. 1 — Foundations of Psychiatric–Mental Health
Nursing — Historical Perspectives / Ethics
Stem: A newly hired nurse reviews unit protocols and notices
that past documentation referred to seclusion practices without
describing rationale or duration. The nurse is concerned about
ethical standards and legal documentation. Which action best
demonstrates appropriate professional practice?
A. Follow existing documentation practice to maintain
continuity with historical records.
B. Ask the charge nurse to review seclusion policies and
implement clear documentation of indications, duration, and