Chapter 11: The Psychiatric–Mental Health Nursing Process

Format: Multiple Choice

Client Needs: Psychosocial Integrity

Cognitive Level: Analyze

Integrated Process: Nursing Process

Objective: 1

Page and Header: 140, Patient Interviews

1. Which question would be most helpful in beginning an initial assessment interview for a client who has just been admitted to a psychiatric inpatient unit?

A) “Have you had any previous psychiatric admissions?”

B) “What brings you into the hospital today?”

C) “Have you had any thoughts about trying to harm yourself?”

D) “How would you describe your relationship with your spouse?”

Page and Header: 142, Box 11.3 Assessment Interview Behaviors

2. A client who is being admitted to a psychiatric unit explains the reason for seeking admission is related to the recent death of a 32-year-old son. Which response by the nurse would enhance the effectiveness of this interview?

A) “How is your spouse handling your son’s death?”

B) “Do you have any other living children that can help you cope with this loss?”

C) “This must be a very difficult time for you.”

D) “I know exactly how you’re feeling; my 23-year-old son died unexpectedly last year.”

Page and Header: 142, Box 11.3 Assessment Interview Behaviors

3. A client was admitted to the hospital after a suicide attempt. The client feels responsible for an automobile accident during which the client suffered only minor injuries, however, the client’s teenage daughter was killed. During the assessment interview, the client speaks about the daughter, makes a visible attempt to “straighten up,” smiles superficially at the nurse, and states, “I’ll get over this. I just need to keep a stiff upper lip. I think all I need to do is stay overnight. I’ll be as good as new by tomorrow.” Which response by the nurse would be most appropriate?

A) “It sounds like you were really close to your daughter. What a shame to lose her at such a young age.”

B) “I’m sure you are right; a good night’s rest should make a big difference.”

C) “As good as new?”

D) “You made a serious attempt on your life; you will not be ready go home by tomorrow.”

Page and Header: 150, Suicide Screening

4. After assessing a client, a nurse noted: “The client was tearful, tried to commit suicide, had no immediate plan for another suicide attempt, was unable to concentrate, and reported having trouble sleeping and having little or no appetite.” The nurse also noted that the client’s appearance was unkempt, and the client spoke with a low monotone voice and was unable to establish and maintain eye contact. Based on this information, which nursing diagnosis would be the most appropriate?

A) Ineffective Role Performance

B) Risk for Infection

C) Risk for Suicide

D) Risk for Self-Mutilation

Page and Header: 155, Sleep Interventions

5. A staff nurse on a psychiatric unit knows that clients often have trouble sleeping because of their psychiatric conditions. What reflects a psychiatric nursing intervention to appropriately address this problem?

A) Limiting amounts of evening snacks and beverages

B) Involving clients in a volleyball game immediately before bedtime

C) Enforcing the rule that all patients be in bed with lights out by 10:30 p.m.

D) Encouraging clients to take short naps in the afternoons

Page and Header: 163, Evaluating Outcomes

6. Based on assessment data, a nurse formulates the nursing diagnosis for a client as sleep pattern disturbance. After educating the client on how to relax before bedtime, the nurse determines that the education was effective based on which outcome?

A) The client discusses feelings about not being able to fall asleep.

B) Within 3 days, the client reports feeling rested upon awakening in the morning.

C) The client requests sleeping medication each night before bedtime.

D) The client is able to sleep for short intervals throughout the night.

Page and Header: 158, Conflict Resolution and Cultural Brokering

7. A migrant worker client is brought to the emergency department for an injury, and it soon becomes evident that the client cannot speak English. A nurse on duty offers to find an interpreter so the client can communicate with the medical staff. The nurse’s offer is an example of which type of nursing intervention?

A) Milieu therapy

B) Conflict resolution

C) Cultural brokering

D) Structured interaction

Page and Header: 162–163, Home Visits

8. A home health nurse is making a home visit to a psychiatric client who was recently discharged from a mental health unit. During the visit, the nurse plans on clarifying with the client when the nurse will return for the next home visit. During which stage would the nurse discuss the next home visit with the client?

A) Closure stage

B) Service implementation

C) Greeting stage

D) Focus establishment

Page and Header: 148, Abstract Reasoning and Comprehension

9. During assessment, a nurse asks a client to explain the meaning of the saying: “A penny saved is a penny earned.” What is the nurse assessing?

A) Affect

B) Attention

C) Concentration

D) Abstract reasoning

Page and Header: 148–149, Self-Concept

10. A nurse identifies a nursing diagnosis of chronic low self-esteem. Which statement by a client would support this nursing diagnosis?

A) “I feel so ugly.”

B) “No one wants to date me.”

C) “I’m so fat, like a cow.”

D) “I never do anything right.”

Page and Header: 153, Spiritual Assessment

11. A nurse is assessing a client’s spirituality. Which question would be most appropriate to ask?

A) “Have you ever tried to harm yourself?”

B) “How important is your family to you?”

C) “How do you define good and evil?”

D) “What gives your life meaning?”

Page and Header: 156, Relaxation Interventions

12. A nurse is assisting a client in using simple relaxation techniques. What would the nurse do first?

A) Have the client assume a relaxed position.

B) Advise the client to let the sensations happen.

C) Ensure a quiet, undisruptive environment.

D) Instruct the client to take an initial slow, deep breath.

Page and Header: 157–158, Counseling Interventions

13. A group of nurses is reviewing information about counseling interventions. The nurses demonstrate a need for additional review when they identify what as a counseling intervention?

A) Identifying specific, time-limited intervention

B) Placing a focus on coping improvement

C) Establishing the goal of regaining functional abilities

D) Focusing on the prevention of disability

Page and Header: 158, Bibliotherapy and Social Media

14. A client is engaged in bibliotherapy and begins to express feelings and associate past experiences with that provided by the reading material. The nurse interprets this using what term?

A) Insight

B) Catharsis

C) Anxiety reduction

D) Problem solving

Page and Header: 161, Milieu Therapy

15. After teaching a group of nursing students about milieu therapy, the instructor determines that additional education is needed when the students identify what as a key concept of milieu therapy?

A) Structure interaction

B) Open communication

C) Validation

D) De-escalation

Page and Header: 148, Recall, Short-Term, Recent, and Remote Memory

16. A nurse is assessing a client’s immediate and short-term memory. Which technique would be most appropriate?

A) Questioning the client about an event that has occurred within the past several months

B) Giving the client a simple scenario and having the client identify what would be the best response

C) Giving the client three words and asking the client to recite them now and then again in 5 minutes

D) Asking the client to tell the nurse the date, time, and current location

Page and Header: 147, Mood and Affect

17. How should the nurse describe the mood and effect of a client who has a mask-like facial expression but states, “I’m really happy?”

A) Congruent

B) Incongruent

C) Restricted

D) Broad

Page and Header: 157, Psychological Interventions

18. A nurse is performing a biopsychosocial assessment of a client with depression. What would the nurse assess as part of the psychological domain? Select all that apply.

A) Abstract reasoning

B) Medication use

C) Mood

D) Orientation

E) Self-care

Page and Header: 148–149, Self-Concept

19. A nurse is reviewing a drawing that a client completed as a self-portrait. The nurse observes that the drawing lacks arms and feet. The nurse interprets this as indicating what feelings? Select all that apply.

A) Low self-esteem

B) Powerlessness

C) Insecurity

D) Inadequacy

E) Loss of symmetry