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Exam (elaborations) TEST BANK PSYCHIATRIC MENTAL HEALTH NURSING 5TH EDITION FORTINASH
Chapter 01: Psychiatric Nursing: Theory, Principles, and Trends
1. Which understanding is the basis for the nursing actions focused on minimizing
mental health promotion of families with chronically mentally ill members?
a. Family members are at an increased risk for mental illness.
b. The mental health care system is not prepared to deal with family crises.
c. Family members are seldom prepared to cope with a chronically ill individual.
d. The chronically mentally ill receive care best when delivered in a formal setting.
ANS: A
When families live with a dominant member who has a persistent and severe mental
disorder the outcomes are often expressed as family members who are at increased risk
for physical and mental illnesses. The remaining options are not necessarily true.
DIF: Cognitive Level: Application REF: Page 3
2. Which nursing activity shows the nurse actively engaged in the primary prevention of
mental disorders?
a. Providing a patient, whose depression is well managed, with medication on time
b. Making regular follow-up visits to a new mother at risk for post-partum
depression
c. Providing the family of a patient, diagnosed with depression, information on
suicide prevention
d. Assisting a patient who has obsessive compulsive tendencies prepare and
practice for a job interview
ANS: B
Primary prevention helps to reduce the occurrence of mental disorders by staying
involved with a patient. Providing medication and information on existing illnesses are
examples of secondary prevention which helps to reduce the prevalence of mental
disorders. Assisting a mentally ill patient with preparation for a job interview is tertiary
prevention since it involves rehabilitation.
DIF: Cognitive Level: Application REF: Page 4
3. Which intervention reflects attention being focused on the patient’s intentions
regarding his diagnosis of severe depression?
a. Being placed on suicide precautions
b. Encouraging visits by his family members
c. Receiving a combination of medications to address his emotional needs
d. Being asked to decide where he will attend his prescribed therapy sessions
ANS: D
A primary factor in patient treatment includes consideration of the patient’s intentions
regarding his or her own care. Patients are central to the process that determines their
care as their abilities allow. Under the guidance of PMH nurses and other mental health
personnel, patients are encouraged to make decisions and to actively engage in their
own treatment plans to meet their needs. The remaining options are focused on specifics
of the determined plan of care.
DIF: Cognitive Level: Application REF: Page 5
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4. When a patient’s family asks why their chronically mentally ill adult child is being
discharged to a community-based living facility, the nurse responds:
a. “It is a way to meet the need for social support.”
b. “It is too expensive to keep stabilized patients in acute care settings.”
c. “This type of facility will provide the specialized care that is needed.”
d. “Being out in the community will help provide hope and purpose for living.”
ANS: D
Hospitalization may be necessary for acute care, but, when patients are stabilized, they
move into community-based, patient-centered settings or are discharged home with
continued outpatient treatment in the community. Concentrated efforts are made to
reduce the patient’s sick role by providing opportunities for the development of a
purposeful life and instilling hope for each patient’s future. Although social support is
important, such a living arrangement is not the only way to achieve it. Although acute
care is expensive, it is not the major concern when determining long-term care options.
Community-based facilities are not the only option for specialized care.
DIF: Cognitive Level: Application REF: Page 5
5. What is the best explanation to offer when the mother of a chronically ill teenage
patient asks, “Under what circumstances would he be considered incompetent?”
a. “When you can provide the court with enough evidence to show that he is not
able to care for himself safely.”
b. “It is not likely that someone his age would be determined to be incompetent
regardless of his mental condition.”
c. “He would have to engage in behavior that would result in harm to himself or to
someone else; like you or his siblings.”
d. “If the illness becomes so severe that his judgment is impaired to the point where
the decisions he makes are harmful to himself or to others.”
ANS: D
When a person is unable to cognitively process information or to make decisions about
his or her own welfare, the person may be determined to be mentally incompetent.
Providing self-care is not the only criteria considered. Age is not a factor considered. The
decision is often based on the potential for such behavior.
DIF: Cognitive Level: Application REF: Page 6
6. Which psychiatric nursing intervention shows an understanding of integrated care?
a. A chronically abused woman is assessed for anxiety.
b. A manic patient is taken to the gym to use the exercise equipment.
c. The older adult diagnosed with depression is monitored for suicidal ideations.
d. A teenager who refuses to obey the unit’s rules is not allow to play video games.
ANS: A
The majority of health disciplines now recognize that mental disorders and physical
illnesses are closely linked. The presence of a mental disorder increases the risk for the
development of physical illnesses and vice versa. Assessing a chronically abused
individual for anxiety call should attention to the psychiatric disorder that could develop
from the abuse. The remaining options show interventions that are appropriate for the
mental disorder.
DIF: Cognitive Level: Application REF: Page 6
7. What reason does the nurse give the patient for the emphasis and attention being
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paid to the recovery phase of their treatment plan?
a. Recovery care, even when intensive, is less expensive than acute psychiatric
care.
b. Effective recovery care is likely to result in fewer relapses and subsequent
hospitalizations.
c. Planning for recovery care is time consuming and involves dealing with many
complicated details.
d. Recovery care is usually done on an outpatient basis and so is generally better
accepted by patients.
ANS: B
Much attention is paid to recovery care since effective recovery care helps improve
patient outcomes and thus minimize subsequent hospitalizations. Recovery care is not
necessarily less expensive than acute care. Although effective recovery care planning
may be time consuming and detail oriented, that is not the reason for implementing it.
Recovery care is not necessarily well accepted by patients.
DIF: Cognitive Level: Application REF: Page 7
8. The nurse is attending a neighborhood meeting where a half-way house is being
proposed for the neighborhood when a member of the community states, “We don’t
want the facility; we especially don’t want violent people living near us.” The
response by the nurse that best addresses the public’s concern is:
a. “In truth, most individuals with psychiatric disorder are passive and withdrawn
and pose little threat to those around them.”
b. “The mentally ill seldom behave in the manner they are portrayed by movies;
they are people just like the rest of us.”
c. “Patients with psychiatric disorder are so well medicated that they do not display
violent behaviors.”
d. “The mentally ill deserve a safe, comfortable place to live among people who
truly care for them.”
ANS: A
A major reason for the existence of the stigma placed on persons with mental illness is
lack of knowledge. The main fear is of violence, although only a small percentage of
patients with mental illness display this behavior. Providing the public with accurate
information can help reduce stigma. The remaining options do not directly address the
concerns stated.
DIF: Cognitive Level: Application REF: Pages 13-14
9. Which activity shows that a therapeutic alliance has been established between the
nurse and patient?
a. The nurse respects the patient’s right to privacy when visitors are spending time
with the patient.
b. The patient is eagerly attending all group sessions and working independently on
identifying their personal stressors.
c. The patient is freely describing their feelings related to the physical and
emotional trauma they experienced as a child with the nurse.
d. The nurse dutifully administers the patient’s medications on time and with
appropriate knowledge of the potential side effects.
ANS: C
A primary aspect of working with patients in any setting and particularly in the
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psychiatric setting is the development of a therapeutic alliance with the patient. Such an
alliance is established on trust. It is a professional bond between the nurse and the
patient that serves as a vehicle for patients to freely discuss their needs and problems in
the absence of the nurse’s criticism or judgment. Any nurse has an obligation to respect
the patient’s rights and administer care effectively. The patient’s willingness to
participate in the plan of care reflects self motivation.
DIF: Cognitive Level: Application REF: Page 9
10. Mental health care reform has called for parity between psychiatric and medical
diagnoses. Which is an example of such parity?
a. Depression treatment is not paid for as readily as is treatment for asthma.
b. The mentally ill patient will be protected by law against social stigma.
c. Medical practitioners are trained to be proficient at treating mental disorders.
d. Psychiatric service reimbursement will be equivalent to that of medical services.
ANS: D
The term parity as used here refers to payments for mental health services that equal
payment schedules for medical or surgical conditions. The remaining options(B and C) do
not relate to financial reimbursement or funds allocated for mental health care being
equal to those of medical diagnoses.
DIF: Cognitive Level: Application REF: Page 15
1. Which assessment findings suggest to the nurse that this patient has characteristics
seen in an individual who has reached self-actualization? Select all that apply.
a. Reports to have, “found peace and security in my religious faith”
b. Effectively “changed occupations” when a chronic vision problem worsened
c. Has consistently earned a six-figure salary as an architect for the last 10 years
d. Has been in a supportive, loving relationship with the same individual for 15
years
e. Provides free literacy tutoring help at the local homeless shelter 3 evenings a
week
ANS: A, B, D, E
Characteristics of self actualization would include: spiritual well-being, open and flexible,
relationally fulfilled, and generosity toward others. Salary doesn’t necessarily reflect selfactualization.
DIF: Cognitive Level: Application REF: Page 4
2. Which nursing activities represent the tertiary level of mental health care? Select all
that apply.
a. Providing a depression screening at a local college
b. Helping a mental-challenged patient learn to make correct change
c. Reporting an incidence of possible elder abuse to the appropriate legal agency
d. Regularly assessing a patient’s understanding of their prescribed antidepressants
e. Providing a 6-week parenting class to teenage parents through a local high school
ANS: B, D
Tertiary prevention reduces the residual effects of the disorder such as depression and
mental retardation. There is no quaternary level of prevention. Primary prevention
reduces occurrences of mental disorders such as screenings and parenting classes, and
secondary prevention reduces the prevalence of disorders as evidenced by assessing
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knowledge.
DIF: Cognitive Level: Application REF: Page 4
3. Which nursing actions indicate an understanding of the priority issues currently
facing psychiatric mental health nursing today? Select all that apply.
a. Working on the facility’s ‘Safe Use of Restraints Policy’ revision committee
b. Advocating for increased salaries for all levels of psychiatric mental health nurses
c. Attending a political rally for increased state funding for mental health service
providers
d. Offering an in-service to facility staff regarding the cultural implications of caring
for the Hispanic patient
e. Joining the state nursing committee working on the role and scope of practice of
the advanced practice psychiatric nurse
ANS: A, C, D, E
Priority issues include funding, safety issues in psychiatric treatment centers—
particularly the use of patient restraints, quality-of-care issues, access to health care for
minority populations, and standardization of advanced practice nurse roles.
DIF: Cognitive Level: Application REF: Page 9
4. Which assessment findings describe risk factors that increase the potential risk for
mental illness? Select all that apply.
a. Possesses high tolerance for stress
b. Is very curious about ‘how things work’
c. Admits to being a member of an ethnic gang
d. Only practicing Jew among school classmates
e. Has a younger sibling who is mentally challenged
ANS: C, D, E
Risk factors are internal predisposing characteristics and external influences that
increase a person’s vulnerability and potential for developing mental disorders. Types of
risk factors and examples include the following: having a mentally-challenged family
member in the home; belonging to a punitive gang; and being the object of reject or
bullying. The remaining options are protective factors.
DIF: Cognitive Level: Application REF: Page 11
5. Which nursing actions show a focus on the fundamental goals that guide psychiatric
mental health nurses in providing patient care? Select all that apply.
a. Offering an informational session of identifying signs of depression at a local
senior center
b. Attending a workshop on evidence practice interventions for the chronically
depressed patient
c. Keeping strict but appropriate boundaries with a patient diagnosed with a
personality disorder
d. Asking a parent who has just experienced the death of a child if they could
consider talking with a grief counselor
e. Identifying what help a patient diagnosed with Alzheimer’s disease will need with
instrumental activities of daily living (IADLs)
ANS: A, B, D, E
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Standard objectives guide PMH nurses and members of related disciplines in the care of
patients (individuals, families, communities, and organizations). The objectives and
criteria are as follows: the promotion and protection of mental health, the prevention of
mental disorders, the treatment of mental disorders, and recovery and rehabilitation.
Keeping appropriate boundaries is a generalized nursing responsibility.
DIF: Cognitive Level: Analysis REF: Page 3
Chapter 02: Nursing Practice in the Clinical Setting
1. Which nursing action is a reflection of Hildegard Peplau’s theoretic framework
regarding psychiatric mental health nursing?
a. Basing patient outcomes on expected instinctual responses
b. Discussing a patient’s feelings regarding parents and siblings
c. Providing the patient with clean clothes and wholesome food
d. Centering professional practice in a state run psychiatric facility
ANS: B
Peplau’s pioneering endeavors and contributions were largely influenced by
interpersonal psychotherapy. She believed that disorders evolved in the social context of
interpersonal interactions. (i.e., what went on between people). Instinctual responses are
more related to intrapersonal interactions. Florence Nightingale was instrumental in the
holistic approach to nursing care, whereas Linda Richards’ practice was centered on
institutional care of the mental ill.
DIF: Cognitive Level: Application REF: Page 18
2. The nurse is attempting to provide a safe environment for a patient at great risk for
self-harm. Which intervention shows an understanding of evidence-based practice
(EBP)?
a. Using physical restraints only after all other options have been proven ineffective
b. Referring to the facility’s policies manual for guidelines for applying physical
restraints
c. Collecting data regarding the short-term effects of using physical restraints on an
aggressive patient
d. Requiring constant monitoring of a patient whose inability to self-regulate anger
has required the use of physical restraints
ANS: B
Health care systems are participating in the shift in nursing practice by encouraging
research in their facilities and by implementing interventions that increase nurses’
knowledge about EBP. Nurses are participating to make evidence-based nursing
practices available for their use, and they are helping to determine the outcomes that
will benefit patients. The remaining options are examples of long-standing practice
related to the use of physical restraints.
DIF: Cognitive Level: Application REF: Page 19
3. Which statement by the patient reflects patient education that was based on the
concept of integrated patient care?
a. “I know I’m anxious when I get a tension headache.”
b. “My anxiety is a result of stressors I don’t cope well with.”
c. “Medication has helped me tremendously with anxiety control.”
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d. “Anxiety runs in my family; my entire family is trying to deal with it.”
ANS: A
Integrated patient care is the recognition of the interplay between physical and mental
health. In integrated care, these disorders are not treated as separate illnesses; rather,
they are treated together. The remaining options make no mention of a relationship
between mental and physical illness.
DIF: Cognitive Level: Application REF: Page 19
4. The nurse demonstrates objective patient care when:
a. Being sympathetic to the patient’s recent loss of a spouse
b. Protecting the anxious patient by eliminating stressors in the milieu
c. Responding to the patient by stating, “I know exactly how you feel.”
d. Facilitating the patient’s exploration of various stress reduction techniques
ANS: D
The nurse demonstrates objectivity by helping the patient to process and organize
thoughts that are directed toward the solving of his or her own problems. With
sympathy, the nurse loses objectivity and moves into his or her own personal feelings.
Removing all stress does not allow the patient to develop necessary coping skills.
DIF: Cognitive Level: Application REF: Pages 21- 22
5. Which nursing intervention would be appropriately addressed during the orientation
phase of the nurse–patient relationship?
a. Self reflection by the nurse regarding personal biases and prejudices regarding
the patient
b. Patient works at prioritizing personal needs and develops realistic expected
outcomes
c. Establishing the contract between the nurse and the patient regarding mutual
needs and expectations
d. Patient commits to the reinforcement of positive personal characteristics while
working on problems and concerns
ANS: C
A contract or agreement is established during the orientation phase of the relationship.
The contract defines limits and expectations of both the patient and the nurse. Self
Reflection occurs during the pre-orientation phase while the remaining options are
addressed during the working phase of the relationship.
DIF: Cognitive Level: Analysis REF: Page 22
6. Which action on the part of a novice psychiatric mental health nurse shows a need
for future development of altruism?
a. Excusing a patient from attending group because, “all that talking makes me so
anxious”
b. Not permitting two patients who are physically attracted to each other to engage
in public displays of affection
c. Placing a physically aggressive patient in restraints when they are unable to
internally calm their anger
d. Self-reflecting on “why I continue to work with patients who are so emotionally
damaged they will never be normal”
ANS: A
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This option shows a misguided kindness that will ultimately have a negative impact on
the patient’s treatment. The remaining options show responsible nursing interventions
that include self-reflection of personal motivation for such work.
DIF: Cognitive Level: Application REF: Page 24
7. The greatest negative outcome resulting from a nurse’s fear of a mentally ill patient
is that the:
a. Nurse will reinforce negative stereotyping of the mentally ill.
b. Patient will experience increased bias against the nursing staff.
c. Public’s fearfulness of the mentally ill will continue to be exaggerated.
d. Therapeutic alliance between the nurse and patient will not develop effectively.
ANS: D
Unrealistic preconceived images, stereotyping, and biases have an effect on nurses that,
when resulting in fear, will negatively impact the therapeutic effectiveness of the nurse
and the care provided. The remaining options do not have the priority that providing
quality patient care has.
DIF: Cognitive Level: Application REF: Page 26
8. Which action on the part of a novice mental health nurse will best minimize fear
related to effectively working with the psychotic patient?
a. Be knowledgeable about psychotropic medications and their affect on psychosis.
b. Always arrange for staff support when working one-on-one with a psychotic
patient.
c. Take advantage of opportunities to attend workshops devoted to the care of the
psychotic patient.
d. Recognize that the psychotic patient is not in control of their behaviors due to
their altered though processes.
ANS: C
Fear breeds avoidance, but knowledge and preparation diminish fear and bring
confidence. Being prepared before entering the psychiatric setting includes having
knowledge and understanding of mental disorders. The remaining options do not provide
confidence but rather means of controlling or avoiding the psychotic patient.
DIF: Cognitive Level: Analysis REF: Page 26
9. Which response by the nurse manager to a novice mental health nurse is most
effective when the nurse asks, “How do I justify not keeping a patient’s secret?”
a. “Never promise the patient that you will keep a secret for them.”
b. “Always stop the patient from telling you something as a secret.”
c. “Let the patient know that you will not keep a secret that could ultimately cause
harm or affect their treatment.”
d. “Keep reminding yourself that you are not the patient’s friend but rather a
professional mental health provider.”
ANS: C
Nurses and other healthcare professionals do not keep secrets or make promises to
patients when the secret may interfere with the patient’s treatment or put them or
others at risk for harm. The remaining options offer appropriate nursing actions but do
not effectively answer the nurse’s question.
DIF: Cognitive Level: Analysis REF: Page 30
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10. The nurse is effectively facilitating the nurse-patient relationship when:
a. Sharing with an angry patient who is verbally abusive that, “Although I can
accept that you are angry, I cannot and will not accept your verbal abuse.”
b. Focusing on the patient’s life experience without relating to the similarities of
one’s own experiences
c. Objectively providing constructive criticism that is directed to helping the patient
identify inappropriate behaviors
d. Refraining from abandoning the patient regardless of the frustration the
interaction causes
ANS: A
Accepting the patient’s feelings is essential; however, it is not necessary to accept all of
the patient’s behaviors. Assist the patient by setting limits on patient behaviors that are
self-defeating or that threaten the patient or others in any way. Setting these limits
allows for mutual respect in the therapeutic alliance. The remaining options enhance the
patient’s clinical experience rather than the nurse-patient relationship.
DIF: Cognitive Level: Application REF: Page 35
11. An often expressed intrinsic reward of psychiatric mental health nursing is:
a. Seeing the seriously ill recover their health
b. Working with patients of all ages and walks of life
c. Working with well-trained, caring health care providers
d. Having time to really focus on the human who is the patient
ANS: D
Psychiatric mental health nurses are able to spend the time to know the patient not only
as a patient but as an individual. This is an opportunity most nurses whose practice is
based on the physical care of the patient is not afforded. The remaining options are not
necessarily unique to psychiatric nursing.
DIF: Cognitive Level: Application REF: Page 36
12.Which statement is an example of an inference?
a. “He is an alcoholic because his wife nags a lot.”
b. “He states he binges after arguing with his wife.”
c. “You say your alcohol intake exceeds a quart a day.”
d. “So you are saying that you were drinking earlier today.”
ANS: A
An inference is an interpretation of behavior that is made by finding motive and forming
conclusions without having all the necessary information. The nurse interprets the
patient’s behavior, decides on a reason, assigns a motive, and forms a conclusion. The
remaining options are validations of observations.
DIF: Cognitive Level: Application REF: Page 34
1. Which interactions are likely outcomes of a well-established therapeutic alliance?
Select all that apply.
a. The nurse states, “I’m not here to judge but rather to help.”
b. The patient states, “I really think I can handle this problem now.”
c. The patient asks his abusive father to attend counseling with him.
d. The nurse sets boundaries for a patient who has few social skills.
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e. The patient with anger issues voluntarily goes into the seclusion room.
ANS: A, B, C, E
The alliance serves as a vehicle that provides patients with an opportunity to freely
discuss their needs and problems in the absence of judgment and criticism, to gain
insight into their abilities, to practice new coping skills, and to heal emotional wounds.
Setting boundaries is not an outcome of such an alliance.
DIF: Cognitive Level: Application REF: Page 19
2. Which nursing interventions are directly related to the principles on which a
therapeutic alliance is based? Select all that apply.
a. Graciously declining to, “Come visit when I get discharged.”
b. Establishing the topic to be discussed at each group session
c. Explaining to the patient the purpose of terminating the alliance
d. Sharing how the nurse also has experienced the same problems
e. Providing subjective feedback to the patient’s efforts at therapy
ANS: A, B, C
The principles that focus on the development and maintenance of a healthy alliance
include: the relationship is therapeutic rather than social; the focus remains on the
patient’s needs and problems rather than on the nurse; the relationship is purposeful
and goal directed; the relationship is objective rather than subjective in quality; and the
relationship is time-limited rather than open-ended. The sharing of experiencing is not
patient centered.
DIF: Cognitive Level: Application REF: Page 20
3. The nurse is attempting to minimize the group’s display of resistance during a
therapy session. Which patients are at risk for displaying such behavior? Select all
that apply
a. The patient who is cognitively impaired
b. The patient who is older and well educated
c. The patient who is aggressive and attention seeking
d. The patient who has attended similar therapy groups in the past
e. The patient who has been diagnosed with paranoid schizophrenia
ANS: A, D, E
A patient who redirects the focus away from himself or herself by changing the subject is
engaging in resistance behavior. Patients divert the topic for one or more of several
reasons: a fear of being judged; avoiding the repetition of material that has been
previously discussed; or the inability to stay cognitively focused. The attention-seeking
patient may attempt to monopolize the discussion but not necessarily be at risk for
resisting the topic. Age and education are not risk factors.
DIF: Cognitive Level: Application REF: Pages 20-21
Chapter 03: The Nursing Process and Standards of Practice
1. The patient asks the nurse, “I’ve heard the student nurses talk about the nursing
process. Why is there so much emphasis on using the nursing process?” The
response that explains the need for nurses to understand and use the nursing
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process is:
a. “Do you think you have a better method we might use?”
b. “The nursing process is a systematic problem-solving method encompassing all
components necessary to care for patients.”
c. “Using the nursing process is a way of legitimizing our profession and placing us
on an equal footing with the pure sciences.”
d. “The nursing process is a unidimensional, static, linear approach used to guide
nurses as they make clinical judgments.”
ANS: B
This response best explains the importance of the nursing process by description and
relationship to patient care. Suggesting that the patient may have a better method is
challenging and does not address the question posed by the patient. Providing
legitimacy to the profession is a very limited explanation for use of the nursing process.
The nursing process is not one-dimensional, static, or linear.
DIF: Cognitive Level: Knowledge REF: Page 40
2. When preparing to conduct a nursing history and assessment on a patient
transferred from the emergency department (ED) whose family believes the patient
to be a questionable historian due to cognitive impairment, the nurse initially begins
the interview by:
a. Reviewing the ED chart
b. Contacting the admitting physician
c. Directing the questions to the family members
d. Establishing a line of communication with the patient
ANS: D
The nurse should begin establishing the nurse–patient relationship by initially directing
the questions to the patient. The nurse can confirm information and/or obtain
supplementary information from the sources identified by the other options.
DIF: Cognitive Level: Application REF: Page 40
3. The nurse shows the ability to effectively state a nursing diagnosis reflective of the
implications of depression on a patient’s life processes when stating in the patient’s
plan of care that:
a. Patient outcomes were partially attained. Implementation of present plan to
continue.
b. Patient will initiate and support conversation with nurse therapist by (date 3
weeks in future).
c. Oral medication for anxiety should be administered when depression is assessed
to be at the moderate level.
d. Impaired verbal communication r/t impoverished thoughts secondary to
depression as evidenced by monosyllabic responses.
ANS: D
This statement contains the various components of a nursing diagnosis while expressing
the existence of an altered life process. The remaining options reflect other steps, such
as evaluation and intervention planning.
DIF: Cognitive Level: Application REF: Pages 47-48
4. When engaging in outcomes identification, the nurse:
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a. Interviews and collects patient-focused data
b. Re-assesses the patient’s physical and emotional status evaluation
c. Reviews the patient’s existing problems and projects the results of the nursing
care
d. Considers the patient’s presenting symptoms and identifies nursing-related
problems
ANS: C
Outcomes are projections of expected influence that nursing interventions will have on
the patient. Interviewing and collecting data is involved in the assessment process, reassessing
is involved in the evaluation process, and identifying related nursing problems
is involved in determining appropriate nursing diagnoses.
DIF: Cognitive Level: Application REF: Page 49
5. While discussing assessment of suicidal patients, a novice nurse mentions, “I was
taught to always base my care on concrete, evidence-based scientific reasoning and
never to rely on intuition.” Which response by the experienced nurse shows
understanding of intuitive reasoning?
a. “That’s wise, because intuition went out of favor with the scientific revolution.”
b. “Critical thinking and intuition are at opposite poles. Keep relying on your
expertise.”
c. “It’s possible that intuition about suicidality is generated by transfer of feelings
from the patient to the nurse.”
d. “It’s been determined that intuition is nothing more that extrasensory perception,
so some folks have it, and some don’t.”
ANS: C
A “strong hunch” or a “gut feeling” is an example of intuitive reasoning that is believed
to come from the therapeutic relationship’s sharing of feelings between nurse and
patient. Most nurses agree that intuition is compatible with scientific reasoning, because
both are likely linked to practice and experience. A nurse learns intuitive reasoning
through clinical practice rather than from school or books.
DIF: Cognitive Level: Application REF: Page 45
6. A nurse shows effective critical thinking skills directed towards nursing care of a
cognitively impaired patient who continues to socially isolate by:
a. Clearly stating that the patient must socially interact once daily
b. Documenting that the patient continues to resist socialization
c. Asking the patient to identify which unit activity they are willing to attend
d. Suggesting that staff take the patient with them when running errands off the
unit
ANS: D
Critical thinking in this case involves the creation of alternative solutions to a problem
that was not resolved by conventional methods. The remaining options, although not
inappropriate, do not show critical thinking skills
DIF: Cognitive Level: Application REF: Page 45
7. A depressed patient shares with the nurse that he, “has been thinking about ending
it all”. Based on NANDA recommendations, the nurse:
a. Implements suicide precautions for this patient
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b. Includes ‘Risk for Self Harm’ to the patient’s care plan
c. Documents regarding the patient’s safety every 15 minutes
d. Reviews the patient’s chart for references to past incidences of hopeless
ANS: B
NANDA states that a nurse is able to change any actual diagnosis on the NANDA list to a
risk diagnosis if the problem has not occurred yet. The remaining options, although not
inappropriate, do not related to NANDA.
DIF: Cognitive Level: Application REF: Page 48
8. The nurse shows an understanding of the appropriate use of nursing outcomes
regarding triggers for a patient diagnosed with chronic alcohol abuse when stating:
a. "Can you work on identifying three situations that cause you to abuse alcohol?”
b. ”I’ll help you to identify three triggers for your drinking during today’s session.”
c. ”I’m pleased you’ve identified three situations that trigger your abuse of alcohol.”
d. “Do you think you will be able to avoid the three triggers that cause you to
drink?”
ANS: C
Outcomes sometimes referred to as behavioral goals are used to describe and evaluate
the effectiveness of nursing interventions. The correct option shows that the patient was
successful at accomplishing an outcome inferring the nursing interventions were
successful. The remaining options do not indicate an evaluation of success or failure.
DIF: Cognitive Level: Application REF: Page 49
9. When a patient experiencing acute depression asks what the difference is between a
medical and a nursing diagnosis, the nurse responds best when stating:
a. Actually they are very similar in that they both are concerned with helping you
get better and lead a happier life.
b. Medical diagnoses are focused on why you are depressed whereas nursing
diagnoses are concerned about making your life less sad.
c. Nursing diagnoses are more directed at caring for you, unlike medical diagnoses
that focus on finding the cause for your problem.
d. The medical diagnosis identifies that you are experiencing depression whereas
the nursing diagnosis identifies how the depression is affecting you.
ANS: D
The medical diagnosis involves identifying a mental or physical problem that results in
the symptoms that negatively affect a patient’s life. Although the nurse is
knowledgeable about the disorders and their treatments, the nursing diagnosis focuses
mainly on the patient’s responses to the disorder and the effects that the disorder has on
the patient. The types of diagnoses have different foci that result in different actions and
concerns.
DIF: Cognitive Level: Application REF: Page 49
10. A nurse best shows an understanding of the role of evidence-based research in
achieving therapeutic patient care outcomes when:
a. Subscribing to and reading a monthly psychiatric research nursing journal
b. Working on a committee to revise current facility policies regarding the use of
chemical restraints
c. Registering to attend a psychiatric workshop on newly developed psychotropic
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medication therapies
d. Asking an experienced staff member to review the interventions being proposed
for a newly admitted patient
ANS: B
Evidence-based practice is based on evidence and scientific principles that have been
developed through research. The more closely clinical practice reflects relevant research,
the more likely it is that patients will receive the best available care. The option that
infers action directed at implementing the research is the one that shows best
understanding. Reliance only on experience is not reflective of quality nursing care.
DIF: Cognitive Level: Application REF: Page 51
11.When caring for a patient admitted with a diagnosis if bipolar disorder, managed care
regulations is the driving force behind the nurse’s use of:
a. NANDA nursing diagnoses
b. Short-term stress management therapy
c. A specialized clinical pathway for such patients
d. Generic instead of brand name medications
ANS: C
Managed care regulations have brought about the use of clinical pathways (also called
critical pathways or a care maps) which are standardized multidisciplinary planning tools
that monitor patient care through projected caregiver interventions and expected patient
outcomes with a projected timeline of success. NANDA nursing diagnoses are not related
to regulations or payment concerns. The implementation of short-term stress
management therapy in an acute care psychiatric environment would not be driven by
managed care regulation or payment concerns. The use of generic medications when
appropriate is primarily cost driven.
DIF: Cognitive Level: Application REF: Page 51
12. A benefit of the implementation of clinical pathways is evidenced when the patient
states:
a. “I know my doctors and nurses really care about me.”
b. “My medication has really helped lessen my symptoms.”
c. “I have hopes that I will be able to lead a productive, healthy life.”
d. “My care team has really helped me manage most of my problems.”
ANS: D
Clinical pathways are tools that among other things promote interdisciplinary care thus
providing for holistic care of the patient. The remaining options do not involve the
additional recognized benefits of clinical pathways that include cost effectiveness and
access to patient status reports.
DIF: Cognitive Level: Application REF: Page 54
13. A nurse shows the best understanding of the legal importance of the patient’s chart
when stating:
a. “You always document in ink and never erase or use “white out” in the nursing
notes.”
b. “It’s a document that shows proof that the patient received care that met the
expected standards.”
c. “Patient charts are carefully protected from unlawful access by inappropriate
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individuals or institutions.”
d. “The patient has a legal right to the information contained in the chart but not
the original documentation itself.”
ANS: B
The patient’s chart is a legal document that effectively communicates patient outcomes,
medications, treatments, responses, and unusual incidents reflecting the healthcare
systems attempts at meet the standard of care appropriate for this patient. The other
options are not as inclusive in describing the legal status of the chart.
DIF: Cognitive Level: Application REF: Page 56
14. The nurse best fulfills the obligation to be accountable for providing care that meets
the expected standards of care when:
a. Developing a therapeutic relations with the patient
b. Applying evidence-based nursing practice [Show Less]