Psychiatric Mental Health Nursing 2nd Edition Scope and Standards of Practice Test Bank

. Chapter 1. – Chapter 4 Assessment Chapter 2 Diagnosis Chapter 3 Outcomes
Identification Chapter 4 Planning
. MULTIPLE CHOICE
. 1. A nurse teaching a patient about the effects and side effects of the prescribed
medication bases the plan on the knowledge that learning is more effective when:
.
a
.
. patients are actively included in the process.
.
b
.
. topics are introduced only when the patient expresses an interest.
.
c
.
. nurses establish realistic goals for learning on behalf of the
patient.
.
d
.
. patients have responsibility for directing the teaching-learning
process.
.
. ANS: A
. Learning is more effective when patients participate in the learning experience.
By including patients as active participants, the nurse helps restore their sense of control over
their life and over their responsibility for their own actions.
.

. DIF: Cognitive Level: Comprehension REF: Text Page: 152
. TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and
Maintenance
. 2. A nurse interviewed a reluctant patient who answered questions with minimal
responses and rarely made eye contact. When documenting baseline data collected in the
interview, the nurse should include:
.
a
.
. interview content only.
.
b
.
. a description of the process of the interview.
.
c
.
. both the content and the process of the interview.
.
d
.
. both factual data about the patient and the nurses emotional
reaction.
.
. ANS: C
. It is important to document both baseline content and process. In addition to the
verbal content of the interview, the patients nonverbal messages and the nurses reactions to the
patient give important clues to the patients state.
.
. DIF: Cognitive Level: Application REF: Text Page: 150
. TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity
. 3. While gathering a baseline history about a patient, a nurse is told by a team
social worker that the patient acts weird and has bad hygiene. The nurses responsibility is to:
.
a
.
. accept the data without question.
.
b
.
. form impressions based on data personally gathered.
.
c
.
. document the impression of the team social worker.
.
d
.
. discuss the social workers impression with the patient.
.
. ANS: B
. In using information from secondary sources, nurses should not simply accept the
assessment of another health care team member; instead, they should apply the information they
obtain to their nursing framework for data collection and formulate their own impressions and
diagnoses. This brings another perspective to the work of the health care team and promotes an
unbiased receptivity to patients and their problems.
.
. DIF: Cognitive Level: Application REF: Text Page: 152
. TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity
. 4. To obtain the clearest clinical information about a patient, a nurse who used
several secondary sources, including the patients spouse and the report of the admitting
psychiatrist, will seek validation from:
.
a
.
. the patient.
.
b
.
. psychiatric nursing textbooks.
.
c. the patients extended family.