A nurse who is admitting a client to the inpatient unit conducts a comprehensive
assessment. How does the nurse use the data gathered from the assessment?
Standard Text: Select all that apply.
1. To support nursing diagnoses
2. To determine the length of stay
3. To exclude data from secondary sources
4. To plan appropriate interventions
5. To make sound clinical judgments
Answer:
The psychiatric”mental health nurse is asked to develop an intervention for the nursing
unit based on Watson’s theory of caring. Given this assignment, which intervention is
most appropriate for the nurse to implement?
1. One-to-one debriefing sessions each week with individual unit nurses and the unit
manager
2. Clarification of values and cultural beliefs that might pose barriers to caring for
clients
3. Identification of additional coping skills for new nurses on the unit
4. Discussion of the impact of recent changes in hospital policy on the nursing staff
Answer:
The correct response of the nurse who is asked if Florence Nightingale had any impact
on the role of the nurse in psychiatric”mental health nursing should be which of the
following?
1. “No, Nightingale focused her ideas on nursing education rather than direct client
care.”
2. “Yes, Nightingale was among the first to note that the influence of nurses has
psychological components.”
3. “No, Nightingale emphasized the physical environment for healing.”
4. “Yes, Nightingale developed the idea of the therapeutic relationship.”
Answer:
A client with borderline personality disorder gives written notice of intention to leave
the hospital after a voluntary admission. The client tells the nurse, “I will rescind my
notice if you expand my smoking privileges.” The nurse should respond in a way that:
1. Convinces the client to rescind the notice.
2. Provides exceptions to the unit rules.
3. Refers the client to the physician.
4. Consistently reinforces the unit rules.
Answer:
An 18-year-old client who joined the military shortly after graduating from high school
is admitted to the mental health unit for depression and suicidal ideation. He tells the
nurse the military is not what he expected and he wants to go home. The nurse observes
a variance in affect between his interaction with peers and staff. The nurse suspects:
1. Conversion disorder.
2. Factitious disorder.
3. Malingering.
4. Body dysmorphic disorder.
Answer:
The client, a combat veteran, was recently diagnosed with PTSD. Which symptoms, if
present, would be characteristic of PTSD?
Standard Text: Select all that apply.
1. Fear of returning to sleep
2. Fitful sleep
3. Excessive sleeping
4. Hair pulling
5. Terrifying nightmares
Answer:
The nurse reflecting on the nursing role within the mental health team, understands that
the main purpose of delivering care using a multidisciplinary team is to do which of the
following?
1. Maximize the efficiency of the health care team with each team member learning
from the others.
2. Increase the opportunity for interpersonal interaction among the client, family, and
team members.
3. Facilitate the case management process by delivering care using a multidisciplinary
health care team.
4. Make the best use of the different abilities of mental health team members in order to
facilitate client progress.
Answer:
When planning care for clients on the mental health unit, the nurse using principles of
humanism would consider which of the following?
1. Clinical interventions are most effective when they focus on the current actions,
feelings, and concerns of clients.
2. Clients rely on providers to develop solutions for their problems.
3. Emotional stress has a relationship to physical symptoms.
4. The mind”body relationship focuses on biological explanations of illness.
Answer:
The nurse acts on the client’s behalf as an advocate for the client’s needs and best
interests. What principle of bioethics is being demonstrated by the nurse?
1. Veracity
2. Beneficence
3. Fidelity
4. Justice
Answer:
A depressed client asks why a physical exam is necessary before being admitted for
outpatient treatment. The nurse explains to the client that a physical exam will:
1. Provide information about medications the client will need.
2. Make sure the client gets all necessary treatment.
3. Complete the admission process.
4. Ensure the client has not ingested any caustic material or inhaled noxious vapors.
Answer:
Nurses are particularly suited to helping clients become informed consumers of CAM
products and practices. One valid and reliable internet website to which nurses might
refer clients or their family members is:
1. EMedicine.
2. Medscape.
3. Science Daily.
4. NCCAM.
Answer:
When interviewing elders the psychiatric nurse is guided by the knowledge that:
1. Shame may inhibit the expression of feelings in elders.
2. Touch is inappropriate during the interview.
3. Family and staff members may provide inaccurate information.
4. Less time may be needed with elders than with other age groups.
Answer:
A nurse is working with a student on the acute care psychiatric unit. The student asks
the nurse why it is important to assess clients’ values when there are many other more
important issues to attend. Which of the following replies should the nurse emphasize?
1. Health behaviors are strongly influenced by personal values.
2. Values form the scientific rationale for health behaviors.
3. Values regarding health are common across many cultures.
4. Ensure that clients’ values are congruent with nurses’ values.
Answer:
The nurse is caring for a client who was recently admitted to the unit. During the
nursing assessment of the client, the nurse finds the client’s beliefs and actions related to
many health practices to stray from the norm. Which action would be most appropriate
for the nurse to take at this time?
1. Repeat the assessment later in the day.
2. Write a nursing diagnosis to address the “bizarre” beliefs and actions.
3. Inquire as to the culture with which the client identifies.
4. Communicate the findings to the health care team.
Answer:
The nurse is admitting a client to the unit for acute alcohol intoxication. In planning the
client’s care, which of the following is the priority intervention for this client?
1. Check for seizure precaution equipment
2. Darken the room
3. Monitor vital signs frequently
4. Restrain the client when restless
Answer:
A teen is brought to the emergency room by a parent. The assessment reveals that the
client has been acting strangely for the past three hours and is hypervigilant, grandiose,
and irritable. Vital signs indicate hypertension, tachycardia, and some arrhythmias. The
teen may have ingested:
1. Alcohol.
2. Crack.
3. Cocaine.
4. Amphetamines.
Answer:
A mental health client is admitted to the psychiatric unit one month after abdominal
surgery. During the initial assessment, the nurse asks the client about pain. In order to
provide culturally competent care, the nurse should not:
1. Acknowledge that each client holds various beliefs about pain.
2. Abstain from stereotyping a client’s pain responses based on the person’s culture.
3. Assume that all clients will verbally express their pain and ask for medication.
4. Respect the client’s right to react to pain in whatever manner desired.
Answer:
When a client with a major depressive disorder states, “I don”t care about anything
anymore,” the nurse would respond:
1. “You have such a good life!”
2. “Are you feeling suicidal?”
3. “What about your children? They are so cute and wonderful!”
4. “Don”t worry. You”ll feel better tomorrow.”
Answer:
A community health-planning group is meeting to discuss increasing violence among
children in the community. Which setting would be expected to have the lowest
occurrence of violence?
1. Schools
2. Streets
3. Residential centers
4. Homes
Answer: