Download Essentials of Psychiatric Mental Health Nursing 7th Edition By Mary C - Test Bank and more Exams Nursing in PDF only on Docsity! Essentials of Psychiatric Mental Health Nursing 7th Edition By Mary C - Test Bank Description INSTANT DOWNLOAD WITH ANSWERS Essentials of Psychiatric Mental Health Nursing 7th Edition By Mary C Chapter 6: Relationship Development and Therapeutic Communication Multiple Choice Identify the choice that best completes the statement or answers the question. 1. What is the most essential task for a nurse to accomplish prior to forming a therapeutic relationship with a client? 1. Clarify personal attitudes, values, and beliefs. 2. Obtain thorough assessment data. 3. Determine the client’s length of stay. 4. Establish personal goals for the interaction. Essentials of Psychiatric Mental Health Nursing 7th Edition By Mary C - Test Bank 2. If a client demonstrates transference toward a nurse, how should the nurse respond? 1. Promote safety and immediately terminate the relationship with the client. 2. Encourage the client to ignore these thoughts and feelings. 3. Immediately reassign the client to another staff member. 4. Help the client to clarify the meaning of the relationship, based on the present situation. 3. What should be the priority nursing action during the orientation (introductory) phase of the nurse-client relationship? 1. Acknowledge the client’s actions, and generate alternative behaviors. 2. Establish rapport and develop treatment goals. 3. Attempt to find alternative placement. 4. Explore how thoughts and feelings about this client may adversely impact nursing care. 4. Which client action should a nurse expect during the working phase of the nurse- client relationship? 1. The client gains insight and incorporates alternative behaviors. 2. The client establishes rapport with the nurse and mutually develops treatment goals. 3. The client explores feelings related to reentering the community. 4. The client explores personal strengths and weaknesses that impact behavioral choices. 5. Which client statement should a nurse identify as a typical response to stress most often experienced in the working phase of the nurse-client relationship? 1. “I can’t bear the thought of leaving here and failing.” 2. “I might have a hard time working with you, because you remind me of my mother.” 3. “I really don’t want to talk any more about my childhood abuse.” Essentials of Psychiatric Mental Health Nursing 7th Edition By Mary C - Test Bank 2. The therapeutic technique of defending 3. The nontherapeutic technique of presenting reality 4. The nontherapeutic technique of giving reassurance 13. A client diagnosed with posttraumatic stress disorder related to a rape is admitted to an inpatient psychiatric unit for evaluation and medication stabilization. Which therapeutic communication technique might a nurse use that is an example of “broad openings”? 1. “What occurred prior to the rape, and when did you go to the emergency department?” 2. “What would you like to talk about?” 3. “I notice you seem uncomfortable discussing this.” 4. “How can we help you feel safe during your stay here?” 14. A nurse maintains an uncrossed arm and leg posture when communicating with a client. This nonverbal behavior is reflective of which letter of the SOLER acronym for active listening? 1. S 2. O 3. L 4. E 5. R 15. An instructor is correcting a nursing student’s clinical worksheet. Which instructor statement is the best example of effective feedback? 1. “Why did you use the client’s name on your clinical worksheet?” 2. “You were very careless to refer to your client by name on your clinical worksheet.” 3. “Surely you didn’t do this deliberately, but you breeched confidentiality by using names.” 4. “It is disappointing that after being told you’re still using client names on your worksheet.” Essentials of Psychiatric Mental Health Nursing 7th Edition By Mary C - Test Bank 16. What is a nurse’s purpose for providing appropriate feedback? 1. To give the client good advice 2. To advise the client on appropriate behaviors 3. To evaluate the client’s behavior 4. To give the client critical information 17. A client exhibiting dependent behaviors says, “Do you think I should move from my parent’s house and get a job?” Which nursing response is most appropriate? 1. “It would be best to do that in order to increase independence.” 2. “Why would you want to leave a secure home?” 3. “Let’s discuss and explore all of your options.” 4. “I’m afraid you would feel very guilty leaving your parents.” 18. A mother rescues two of her four children from a house fire. In an emergency department, she cries, “I should have gone back in to get them. I should have died, not them.” What is the nurse’s best response? 1. “The smoke was too thick. You couldn’t have gone back in.” 2. “You’re experiencing feelings of guilt, because you weren’t able to save your children.” 3. “Focus on the fact that you could have lost all four of your children.” 4. “It’s best if you try not to think about what happened. Try to move on.” 19. A newly admitted client, diagnosed with obsessive-compulsive disorder (OCD), washes his hands continually. This behavior prevents unit activity attendance. Which nursing statement best addresses this situation? Essentials of Psychiatric Mental Health Nursing 7th Edition By Mary C - Test Bank 1. “Everyone diagnosed with OCD needs to control their ritualistic behaviors.” 2. “It is important for you to discontinue these ritualistic behaviors.” 3. “Why are you asking for help, if you won’t participate in unit therapy?” 4. “Let’s figure out a way for you to attend unit activities and still wash your hands.” Multiple Response Identify one or more choices that best complete the statement or answer the question. 20. Which of the following characteristics should be included in a therapeutic nurse-client relationship? (Select all that apply.) 1. Meeting the psychological needs of the nurse and the client 2. Ensuring therapeutic termination 3. Promoting client insight into problematic behavior 4. Collaborating to set appropriate goals 5. Meeting both the physical and psychological needs of the client 21. Which of the following individuals are communicating a message? (Select all that apply.) 1. A mother spanking her son for playing with matches 2. A teenage boy isolating himself and playing loud music 3. A biker sporting an eagle tattoo on his biceps 4. A teenage girl writing, “No one understands me” 5. A father checking for new email on a regular basis Completion Complete each statement. Essentials of Psychiatric Mental Health Nursing 7th Edition By Mary C - Test Bank 3 This option would not be therapeutic to the client, who may continue to displace feelings onto others. The nurse should respond to a client’s transference by clarifying the meaning of 4 the nurse-client relationship based on the present situation. Transference occurs when the client unconsciously displaces feelings about a person from the past toward the nurse. PTS: 1 CON: Patient-Centered Care 3. ANS: 2 Chapter: Chapter 6, Relationship Development and Therapeutic Communication Objective: Describe the phases of relationship development and the tasks associated with each phase. Page: 129 Heading: Phases of Therapeutic Nurse-Client Relationship > The Orientation (Introductory) Phase Integrated Processes: Nursing Process Client Need: Psychosocial integrity Cognitive Level: Application [Applying] Concept: Communication Difficulty: Easy Feedback 1 Acknowledging the client’s actions and generating alternative behaviors can occur after rapport has been established. 2 The priority nursing action during the orientation phase of the nurse-client relationship should be to establish rapport and develop treatment goals. Rapport implies feelings on the part of both the nurse and the client, based on respect, acceptance, a sense of trust, and a nonjudgmental attitude. It is the essential Essentials of Psychiatric Mental Health Nursing 7th Edition By Mary C - Test Bank foundation of the nurse-client relationship. 3 Attempting to find alternative placement can occur after rapport has been established. 4 Exploring how thoughts and feelings about this client may adversely impact nursing care can occur after rapport has been established. PTS: 1 CON: Communication 4. ANS: 1 Chapter: Chapter 6, Relationship Development and Therapeutic Communication Objective: Describe the phases of relationship development and the tasks associated with each phase. Page: 129 Heading: Phases of Therapeutic Nurse-Client Relationship > The Working Phase Integrated Processes: Nursing Process Client Need: Psychosocial integrity Cognitive Level: Application [Applying] Concept: Communication Difficulty: Easy Feedback 1 The nurse should expect that the client will gain insight and incorporate alternative behaviors during the working phase of the nurse-client relationship. 2 Establishing rapport with the nurse and mutually developing treatment goals occurs before the working phase. 3 Exploring feelings related to reentering the community does not occur during the working phase. 4 Exploring personal strengths and weaknesses that impact behavioral choices does Essentials of Psychiatric Mental Health Nursing 7th Edition By Mary C - Test Bank not occur during the working phase. PTS: 1 CON: Communication 5. ANS: 3 Chapter: Chapter 6, Relationship Development and Therapeutic Communication Objective: Describe the phases of relationship development and the tasks associated with each phase. Page: 129 Heading: The Working Phase Integrated Processes: Nursing Process Client Need: Psychosocial integrity Cognitive Level: Analysis [Analyzing] Concept: Communication Difficulty: Easy Feedback 1 Stating, “I can’t bear the thought of leaving here and failing,” does not indicate resistance to the therapeutic relationship between the nurse and client. Stating, “I might have a hard time working with you, because you remind me of 2 my mother,” does not indicate resistance to the therapeutic relationship between the nurse and client. The nurse should identify that the client statement, “I really don’t want to talk any more about my childhood abuse,” reflects that the client is in the working phase of 3 the nurse-client relationship. The working phase includes overcoming resistance behaviors on the part of the client as the level of anxiety rises in response to discussion of painful issues. 4 Stating, “I’m not sure that I can count on you to protect my confidentiality,” does not indicate resistance to the therapeutic relationship between the nurse and client. Essentials of Psychiatric Mental Health Nursing 7th Edition By Mary C - Test Bank Chapter: Chapter 6, Relationship Development and Therapeutic Communication Objective: Identify and discuss essential conditions for a therapeutic relationship to occur. Page: 129 Heading: Phases of a Therapeutic Nurse-Client Relationship > The Working Phase Integrated Processes: Nursing Process Client Need: Psychosocial integrity Cognitive Level: Application [Applying] Concept: Communication Difficulty: Easy Feedback 1 Establishing a contract for intervention would occur in the orientation phase. 2 Examining feelings about working with a client should occur in the preinteraction phase. 3 Establishing a plan for aftercare would occur in the termination phase. 4 The nurse should place priority on promoting the client’s insight and perception of reality during the working phase of relationship development. PTS: 1 CON: Communication 9. ANS: 1 Chapter: Chapter 6, Relationship Development and Therapeutic Communication Objective: Describe therapeutic and nontherapeutic verbal communication techniques. Page: 137–138 Heading: Table 6-3 Therapeutic Communication Techniques Essentials of Psychiatric Mental Health Nursing 7th Edition By Mary C - Test Bank Integrated Processes: Nursing Process Client Need: Psychosocial integrity Cognitive Level: Application [Applying] Concept: Communication Difficulty: Easy Feedback The nurse is using the therapeutic communication technique of restatement. 1 Restatement involves repeating the main idea of what the client has said. It allows the client to know whether the statement has been understood and provides an opportunity to continue. 2 Offering general leads does not involve summarizing the client’s statement. 3 Offering focusing does not involve summarizing the client’s statement. 4 Offering accepting does not involve summarizing the client’s statement. PTS: 1 CON: Communication 10. ANS: 3 Chapter: Chapter 6, Relationship Development and Therapeutic Communication Objective: Describe therapeutic and nontherapeutic verbal communication techniques. Page: 137–138 Heading: Table 6-3 Therapeutic Communication Techniques Integrated Processes: Nursing Process Client Need: Psychosocial integrity Cognitive Level: Application [Applying] Concept: Communication Essentials of Psychiatric Mental Health Nursing 7th Edition By Mary C - Test Bank Difficulty: Easy Feedback 1 Reflecting does not explore behavior alternatives. 2 Making observations does not explore behavior alternatives. The nurse is using the therapeutic communication technique of formulating a plan 3 of action to help the client explore alternatives to drinking. The use of this technique may serve to prevent anger or anxiety from escalating. 4 Giving recognition does not explore behavior alternatives. PTS: 1 CON: Communication 11. ANS: 3 Chapter: Chapter 6, Relationship Development and Therapeutic Communication Objective: Describe therapeutic and nontherapeutic verbal communication techniques. Page: 137 Heading: Table 6-3 Therapeutic Communication Techniques; Giving broad openings Integrated Processes: Nursing Process Client Need: Psychosocial integrity Cognitive Level: Application [Applying] Concept: Communication Difficulty: Easy Feedback 1 This is a specific question, not a general lead. 2 This is a closed ended question; it does not encourage the client to elaborate. Essentials of Psychiatric Mental Health Nursing 7th Edition By Mary C - Test Bank Chapter: Chapter 6, Relationship Development and Therapeutic Communication Objective: Describe active listening. Page: 136 Heading: Interpersonal Communication > Active Listening Integrated Processes: Nursing Process Client Need: Psychosocial integrity Cognitive Level: Application [Applying] Concept: Communication Difficulty: Easy Feedback 1 The acronym SOLER includes: sitting squarely facing the client (S). 2 The nurse should identify that maintaining an uncrossed arm and leg posture is nonverbal behavior that reflects the O in the active-listening acronym SOLER. 3 The acronym SOLER includes: leaning forward toward the client (L). 4 The acronym SOLER includes: establishing eye contact (E). 5 The acronym SOLER includes: relaxing (R). PTS: 1 CON: Communication 15. ANS: 3 Chapter: Chapter 6, Relationship Development and Therapeutic Communication Objective: Discuss therapeutic feedback. Page: 138 Heading: Interpersonal Communication > Feedback Essentials of Psychiatric Mental Health Nursing 7th Edition By Mary C - Test Bank Integrated Processes: Nursing Process Client Need: Psychosocial integrity Cognitive Level: Application [Applying] Concept: Communication Difficulty: Easy Feedback 1 Asking questions does not give feedback to the student. 2 Feedback should impart information to the student. The instructor’s statement, “Surely you didn’t do this deliberately, but you 3 breeched confidentiality by using names,” is an example of effective feedback. Feedback is method of communication for helping others consider a modification of behavior. Feedback should be descriptive, specific, and directed toward a behavior that the 4 person has the capacity to modify and should impart information rather than offer advice. PTS: 1 CON: Communication 16. ANS: 4 Chapter: Chapter 6, Relationship Development and Therapeutic Communication Objective: Discuss therapeutic feedback. Page: 138 Heading: Interpersonal Communication > Feedback Integrated Processes: Nursing Process Client Need: Psychosocial integrity Cognitive Level: Application [Applying] Essentials of Psychiatric Mental Health Nursing 7th Edition By Mary C - Test Bank Concept: Communication Difficulty: Easy Feedback 1 Feedback should not be used to give advice. 2 Feedback should not be used to give advice on behaviors. 3 Feedback should not be used to evaluate behaviors. 4 The purpose of providing appropriate feedback is to give the client critical information. PTS: 1 CON: Communication 17. ANS: 3 Chapter: Chapter 6, Relationship Development and Therapeutic Communication Objective: Describe therapeutic and nontherapeutic verbal communication techniques. Page: 139–140 Heading: Table 6-4 Nontherapeutic Communication Techniques Integrated Processes: Nursing Process Client Need: Psychosocial integrity Cognitive Level: Application [Applying] Concept: Communication Difficulty: Easy Feedback 1 Stating, “It would be best to do that in order to increase independence,” does not Essentials of Psychiatric Mental Health Nursing 7th Edition By Mary C - Test Bank attend unit activities and still wash your hands.” This statement reflects the therapeutic communication technique of formulating a plan of action. The nurse attempts to work with the client to develop a plan without damaging the therapeutic relationship. PTS: 1 CON: Communication MULTIPLE RESPONSE 20. ANS: 2, 3, 4, 5 Chapter: Chapter 6, Relationship Development and Therapeutic Communication Objective: Identify and discuss essential conditions for a therapeutic relationship to occur. Page: 125 Heading: The Therapeutic Nurse-Client Relationship Integrated Processes: Nursing Process Client Need: Psychosocial integrity Cognitive Level: Application [Applying] Concept: Communication Difficulty: Moderate Feedback 1. Meeting the nurse’s psychological needs should never be addressed within the nurse- client relationship. 2. The nurse-client therapeutic relationship should include ensuring therapeutic termination. 3. The nurse-client therapeutic relationship should include promoting client insight into problematic behavior. Essentials of Psychiatric Mental Health Nursing 7th Edition By Mary C - Test Bank 4. The nurse-client therapeutic relationship should include collaborating to set appropriate goals. 5. The nurse-client therapeutic relationship should include meeting both the physical and psychological needs of the client. PTS: 1 CON: Communication 21. ANS: 1, 2, 3, 4 Chapter: Chapter 6, Relationship Development and Therapeutic Communication Objective: Identify components of nonverbal expression. Page: 134 Heading: Nonverbal Communication Integrated Processes: Nursing Process Client Need: Psychosocial integrity Cognitive Level: Application [Applying] Concept: Communication Difficulty: Easy Feedback 1. The nurse should determine that a mother spanking her son for playing with matches is a way in which people communicate messages to others. 2. The nurse should determine that a teenage boy isolating himself and playing loud music is a way in which people communicate messages to others. 3. The nurse should determine that a biker sporting an eagle tattoo on his biceps is a way in which people communicate messages to others. 4. The nurse should determine that writing is a way in which people communicate messages to others. 5. Checking for new emails is not an example of communicating a message. Essentials of Psychiatric Mental Health Nursing 7th Edition By Mary C - Test Bank PTS: 1 CON: Communication COMPLETION 22. ANS: rapport Feedback: Rapport implies special feelings on the part of both the client and the nurse, based on acceptance, warmth, friendliness, common interest, a sense of trust, and a nonjudgmental attitude. Establishing rapport may be accomplished by discussing non-health-related topics. Chapter: Chapter 6, Relationship Development and Therapeutic Communication Objective: Identify and discuss essential conditions for a therapeutic relationship to occur. Page: 126 Heading: The Therapeutic Nurse-Client Relationship > Rapport Integrated Processes: Nursing Process Client Need: Psychosocial integrity Cognitive Level: Application [Applying] Concept: Communication Difficulty: Easy PTS: 1 CON: Communication 23. ANS: Essentials of Psychiatric Mental Health Nursing 7th Edition By Mary C - Test Bank 5. Which tool would be appropriate for a nurse to use when assessing mental acuity prior to and immediately following electroconvulsive therapy (ECT)? 1. CIWA scale 2. GGT 3. MMSE 4. CAPS scale 6. What is being assessed when a nurse asks a client to identify name, date, residential address, and situation? 1. Mood 2. Perception 3. Orientation 4. Affect 7. What is the purpose of a nurse gathering client information? 1. It enables the nurse to modify behaviors related to personality disorders. 2. It enables the nurse to make sound clinical judgments and plan appropriate care. 3. It enables the nurse to prescribe the appropriate medications. 4. It enables the nurse to assign the appropriate Axis I diagnosis. 8. A nurse on an inpatient psychiatric unit implements care by scheduling client activities, interacting with clients, and maintaining a safe therapeutic environment. These actions reflect which role of the nurse? 1. Health teacher 2. Case manager 3. Milieu manager 4. Psychotherapist Essentials of Psychiatric Mental Health Nursing 7th Edition By Mary C - Test Bank 9. The following outcome was developed for a client: “Client will list five personal strengths by the end of day one.” Which correctly written nursing diagnostic statement most likely generated the development of this outcome? 1. Altered self-esteem R/T years of emotional abuse AEB self-deprecating statements 2. Self-care deficit R/T altered thought process 3. Disturbed body image R/T major depressive disorder AEB mood rating of 2/10 4. Risk for disturbed self-concept R/T hopelessness AEB suicide attempt 10. How should a nurse prioritize nursing diagnoses? 1. By the established goal of care 2. By the life-threatening potential 3. By the physician’s priority of care 4. By the client’s preference 11. A client has a nursing diagnosis of Insomnia R/T paranoid thinking AEB MNA, DFA, and daytime napping. Which is a correctly written and appropriate outcome for this client? 1. The client will avoid daytime napping and attend all groups. 2. The client will exercise, as needed, before bedtime. 3. The client will sleep seven uninterrupted hours by day four of hospitalization. 4. The client’s sleep habits will improve during hospitalization. 12. The following NANDA-I nursing diagnostic stem was developed for a client on an inpatient unit: Risk for injury. What assessment data most likely led to the development of this problem statement? 1. The client is receiving ECT and is diagnosed with Parkinsonism. Essentials of Psychiatric Mental Health Nursing 7th Edition By Mary C - Test Bank 2. The client has a history of four suicide attempts in adolescence. 3. The client expresses hopelessness and helplessness and isolates self. 4. The client has disorganized thought processes and delusional thinking. 13. A student nurse asks an instructor how best to develop nursing outcomes for clients. Which response by the instructor most accurately answers the student’s question? 1. “You can use NIC, a standardized reference for nursing outcomes.” 2. “Look at your client’s problems and set a realistic, achievable goal.” 3. “With client collaboration, outcomes should be based on client problems.” 4. “Copy your standard outcomes from a nursing care plan textbook.” 14. A client diagnosed with schizophrenia is exhibiting nonverbal behaviors indicating that the client is hearing things that others do not. Which nursing diagnosis, which was recently removed from the NANDA-I list, still accurately reflects this client’s problem? 1. Disturbed thought processes 2. Disturbed sensory perception 3. Anxiety 4. Chronic confusion Multiple Response Identify one or more choices that best complete the statement or answer the question. 15. Which of the following characteristics of accurately developed client outcomes should a nurse identify? (Select all that apply.) 1. Client outcomes are specifically formulated by nurses. 2. Client outcomes are not restricted by time frames. 3. Client outcomes are specific and measurable. Essentials of Psychiatric Mental Health Nursing 7th Edition By Mary C - Test Bank Objective: Identify six steps of the nursing process and describe nursing actions associated with each. Page: 156 Heading: Standards of Practice > Nursing Interventions Classification (NIC) Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 Nursing interventions should be developed and implemented in collaboration with other health-care professionals involved in the client’s care. 2 Nursing interventions are not solely directed by written physician orders. 3 The nurse should understand that nursing interventions occur independently but in concert with overall treatment goals. 4 Nursing interventions are created in conjunction with standardized by policies and procedures. PTS: 1 CON: Patient-Centered Care 3. ANS: 2 Chapter: Chapter 7, The Nursing Process in Psychiatric/Mental Health Nursing Objective: Identify six steps of the nursing process and describe nursing actions associated with each. Page: 156 Heading: The Nursing Process > Standard 5D. Prescriptive Authority and Treatment Essentials of Psychiatric Mental Health Nursing 7th Edition By Mary C - Test Bank Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 Teaching about the side effects of neuroleptic medications can be completed by Registered Nurses. The advanced practice psychiatric nurse is authorized to use psychotherapy to 2 improve mental health. This includes individual, couples, group, and family psychotherapy. 3 Using milieu therapy to structure a therapeutic environment can be completed by Registered Nurses. 4 Providing case management to coordinate continuity of health services can be completed by Registered Nurses. PTS: 1 CON: Patient-Centered Care 4. ANS: 1 Chapter: Chapter 7, The Nursing Process in Psychiatric/Mental Health Nursing Objective: Document client care that validates use of the nursing process. Page: 162 Heading: Documentation of the Nursing Process > Problem-oriented Recording Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Comprehension (Understanding) Essentials of Psychiatric Mental Health Nursing 7th Edition By Mary C - Test Bank Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 The acronym SOAPIE represents problem-oriented charting, which reflects the subjective, objective, assessment, plan, implementation, and evaluation format. 2 APIE does not represent problem-oriented charting. 3 DAR does not represent problem-oriented charting. 4 PQRST does not represent problem-oriented charting. PTS: 1 CON: Patient-Centered Care 5. ANS: 3 Chapter: Chapter 7, The Nursing Process in Psychiatric/Mental Health Nursing Objective: Identify six steps of the nursing process and describe nursing actions associated with each. Page: 147 Heading: The Nursing Process > Assessment Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate Feedback Essentials of Psychiatric Mental Health Nursing 7th Edition By Mary C - Test Bank PTS: 1 CON: Patient-Centered Care 8. ANS: 3 Chapter: Chapter 7 The Nursing Process in Psychiatric/Mental Health Nursing Objective: Apply the six steps of the nursing process in the care of a client within the psychiatric setting. Page: 156 Heading: The Nursing Process > Standard 5F. Milieu Therapy Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 Health teaching involves promoting health in a safe environment. 2 Case management is used to organize client care so that outcomes are achieved. 3 The milieu manager implements care by scheduling client activities, interacting with clients, and maintaining a safe therapeutic environment. 4 Psychotherapy involves conducting individual, couples, group, and family counseling. PTS: 1 CON: Patient-Centered Care Essentials of Psychiatric Mental Health Nursing 7th Edition By Mary C - Test Bank 9. ANS: 1 Chapter: Chapter 7, The Nursing Process in Psychiatric/Mental Health Nursing Objective: Apply the six steps of the nursing process in the care of a client within the psychiatric setting. Page: 159 Heading: Applying the Nursing Process in the Psychiatric Setting Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate Feedback The nurse should determine that altered self-esteem and self-deprecating 1 statements would generate the outcome to list personal strengths by the end of day one. 2 The self-care deficit nursing diagnoses is incorrectly written. 3 Disturbed body image would generate specific outcomes in accordance with specific needs and goals. 4 The risk for disturbed self-concept nursing diagnoses is incorrectly written. PTS: 1 CON: Patient-Centered Care 10. ANS: 2 Chapter: Chapter 7, The Nursing Process in Psychiatric/Mental Health Nursing Objective: Apply the six steps of the nursing process in the care of a client within the psychiatric setting. Essentials of Psychiatric Mental Health Nursing 7th Edition By Mary C - Test Bank Page: 159 Heading: Applying the Nursing Process in the Psychiatric Setting Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Analysis (Analyzing) Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 Client care goals can be met after safety has been established. 2 The nurse should prioritize nursing diagnoses related to their life-threatening potential. Safety is always the nurse’s first priority. 3 The physician’s priority of care can be met after safety has been established. 4 The client can choose a goal as a priority after safety has been established. PTS: 1 CON: Patient-Centered Care 11. ANS: 3 Chapter: Chapter 7, The Nursing Process in Psychiatric/Mental Health Nursing Objective: Apply the six steps of the nursing process in the care of a client within the psychiatric setting. Page: 159 Heading: Applying the Nursing Process in the Psychiatric Setting Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Essentials of Psychiatric Mental Health Nursing 7th Edition By Mary C - Test Bank among the interdisciplinary team members, the client, and significant others. 4 Goals should be personalized for each client. PTS: 1 CON: Patient-Centered Care 14. ANS: 2 Chapter: Chapter 7, The Nursing Process in Psychiatric/Mental Health Nursing Objective: Discuss the list of nursing diagnoses approved by NANDA International for clinical use and testing. Page: 161 Heading: Applying the Nursing Process in the Psychiatric Setting Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 The nursing diagnosis, disturbed thought processes, does not accurately reflect the client’s problem. The nursing diagnosis disturbed sensory perception accurately reflects the client’s 2 symptoms of hearing things that others do not. The nursing diagnosis describes the client’s condition and facilitates the prescription of interventions. 3 The nursing diagnosis, anxiety, does not accurately reflect the client’s problem. 4 The nursing diagnosis, chronic confusion, does not accurately reflect the client’s problem. Essentials of Psychiatric Mental Health Nursing 7th Edition By Mary C - Test Bank PTS: 1 CON: Patient-Centered Care MULTIPLE RESPONSE 15. ANS: 3, 4 Chapter: Chapter 7, The Nursing Process in Psychiatric/Mental Health Nursing Objective: Identify six steps of the nursing process and describe nursing actions associated with each. Page: 155 Heading: Standard 3. Outcomes Identification Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1. Outcomes are most effective when formulated cooperatively by the interdisciplinary team members, the client, and significant others. 2. Outcomes should be given a time frame. 3. The nurse should identify that client outcomes should be specific and measurable. 4. The nurse should identify that client outcomes should be based on client capability. 4. 5. Outcomes do not need to be approved by a psychiatrist. PTS: 1 CON: Patient-Centered Care Essentials of Psychiatric Mental Health Nursing 7th Edition By Mary C - Test Bank ORDERED RESPONSE 16. ANS: 2, 5, 4, 3, 1. Chapter: Chapter 7, The Nursing Process in Psychiatric/Mental Health Nursing Objective: Identify six steps of the nursing process and describe nursing actions associated with each. Page: 147 Heading: The Nursing Process Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Moderate Feedback: Measuring a client’s vital signs and reviewing past history is a nursing intervention that occurs in the assessment step of the nursing process. Recognizing and documenting the client’s problem occurs in the nursing diagnosis step. Setting a goal with client collaboration, for a seven-hour night’s sleep occurs in the planning step. Encouraging deep breathing and teaching relaxation techniques occurs in the implementation step. Determining if an antianxiety medication is decreasing a client’s stress occurs in the evaluation step. PTS: 1 CON: Patient-Centered Care COMPLETION