Psychiatric Mental Health Nursing Concepts of Care in Evidence Based Practice 9th Edition Townsend Test Bank

Psychiatric Mental Health Nursing
Concepts of Care in Evidence Based

Practice 9th Edition Townsend Test
Bank
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Chapter 9. The Nursing Process in Psychiatric-Mental Health Nursing
MULTIPLE CHOICE
1. Which data-gathering technique is employed during the assessment phase of the nursing
process?
A. Asking the client to rate mood after administering an antidepressant
B. Asking the client to verbalize understanding of previously explained unit rules
C. Asking the client to describe any thoughts of self-harm
D. Asking the client if the group on assertiveness skills was helpful
ANS: C
Chapter: Chapter 9, The Nursing Process in Psychiatric-Mental Health Nursing
Chapter learning objective: Identify six steps of the nursing process and describe nursing
actions associated with each.
Page: 165
Heading: The Nursing Process > Standards of Practice > Standard 1. Assessment
Integrated Processes: Nursing Process: Assessment
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Communication
Difficulty: Moderate
Feedback
A This is incorrect. This step is employed during the evaluation phase of the
nursing process.
B This is incorrect. This step is employed during the evaluation phase of the
nursing process.
C This is correct. The nurse should ask the client to describe any thoughts of
self-harm during the assessment phase of the nursing process. Assessment
involves collecting and analyzing data about the client that may include the
following dimensions: physical, psychological, sociocultural, spiritual,
cognitive, developmental, economic, lifestyle, and functional abilities.
D This is incorrect. This step is employed during the evaluation phase of the
nursing process.
PTS: 1 CON: Communication
2. Which statement is most accurate regarding the assessment of clients diagnosed with
psychiatric problems?
A. Medical history is of little significance and can be eliminated from the nursing
assessment.
B. Assessment provides a holistic view of the client, including biopsychosocial
aspects.
C. Comprehensive assessments can be performed only by advanced practice nurses.
D. Psychosocial evaluations are gained by subjective reports rather than objective
observations.
ANS: B
Chapter learning objective: Apply the six steps of the nursing process in caring for a client
within the psychiatric setting.
Page:165–166
Heading: The Nursing Process> Standards of Practice > Standard 1. Assessment
Cognitive Level: Comprehension [Understanding]
Concept: Patient-Centered Care
Feedback
A This is incorrect. A client’s medical history is significant and should be part of
the nursing assessment.
B This is correct. Assessment of clients diagnosed with psychiatric problems
provides a holistic view of the client. A thorough assessment involves collecting
and analyzing data from the client, significant others, and health-care providers
that may include the following dimensions: physical, psychological,
sociocultural, spiritual, cognitive, developmental, economic, lifestyle, and
functional abilities.
C This is incorrect. All registered nurses can perform comprehensive client
assessments.
D This is incorrect. Psychosocial evaluations are gained by both subjective reports
and objective observations.
PTS: 1 CON: Patient-Centered Care
3. Which nursing diagnosis should a nurse identify as being correctly formulated?

A. Schizophrenia R/T biochemical alterations AEB altered thought
B. Self-care deficit: hygiene R/T altered thought AEB disheveled appearance
C. Depressed mood R/T multiple life stressors
D. Developmental disability R/T early-onset schizophrenia AEB hallucinations
ANS: B
Page: 172–173
Heading: The Nursing Process > Appendix F, Assigning NANDA Nursing Diagnoses to
Client Behaviors
Integrated Processes: Nursing Process: Analysis
Feedback
A This is incorrect. The correctly written diagnosis is “Self-care deficit: hygiene
R/T altered thought AEB disheveled appearance.” The nursing diagnosis should
describe the unhealthy response (inference), the contributing factors, and the
data that support the inference.
B This is correct. The correctly written diagnosis is “Self-care deficit: hygiene R/T
altered thought AEB disheveled appearance.” The nursing diagnosis should
C This is incorrect. The correctly written diagnosis is “Self-care deficit: hygiene
D This is incorrect. The correctly written diagnosis is “Self-care deficit: hygiene
4. Which expected client outcome should a nurse identify as being correctly formulated?
A. Client will feel happier by discharge.
B. Client will demonstrate two relaxation techniques.
C. Client will verbalize triggers to anger by end of session.
D. Client will initiate interaction with one peer during free time within 2 days.
ANS: D
Page: 173
Heading: The Nursing Process > Standards of Practice >Standard 3. Outcomes Identification
Integrated Processes: Nursing Process: Planning
Difficulty: Easy
Feedback
A This is incorrect. The statement “Client will initiate interaction with one peer
during free time within 2 days” is an example of a correctly formulated expected
outcome. Outcomes should be measurable, realistic, client-focused goals that
include a time frame. Appropriate nursing interventions are guided by client
outcomes.
B This is incorrect. The statement “Client will initiate interaction with one peer
outcomes.
C This is incorrect. The statement “Client will initiate interaction with one peer
outcomes.
D This is correct. The statement “Client will initiate interaction with one peer
outcomes.
5. Which statement regarding nursing interventions should a nurse identify as accurate?

A. Nursing interventions are independent of the treatment team’s goals.
B. Nursing interventions are directed solely by written physician orders.
C. Nursing interventions occur independently but align with overall treatment team
goals.
D. Nursing interventions are standardized by policies and procedures.
ANS: C
Page: 174
Heading: The Nursing Process > Standards of Practice > Standard 4. Planning
Integrated Processes: Nursing Process: Implementation
Feedback
A This is incorrect. Nursing interventions occur independently but are also in
concert with overall treatment goals. They should be developed and
implemented in collaboration with other health-care professionals involved in
the client’s care.
B This is incorrect. Nursing interventions are not directed by physician orders.
Nursing interventions should be developed and implemented in collaboration
with other health-care professionals involved in the client’s care.
C This is correct. Nursing interventions occur independently but are also in
concert with overall treatment goals. Nursing interventions should be developed
and implemented in collaboration with other health-care professionals involved
in the client’s care.
D This is incorrect. Nursing interventions are not standardized by policies and
procedures. Nurses formulate nursing interventions designed to meet each
client’s individual needs. Nursing interventions should be developed and
implemented in collaboration with other health-care professionals involved in
the client’s care.

6. Which function is exclusive to the advance practice psychiatric nurse’s scope of practice?
A. Teaching about the side effects of neuroleptic medications
B. Using psychotherapy to improve mental health status
C. Using milieu therapy to structure a therapeutic environment
D. Providing case management to coordinate continuity of health services
ANS: B
Chapter learning objective: Define and discuss the use of case management and critical
pathways of care in the clinical setting.
Page: 174
Heading: The Nursing Process > Standards of Practice > Standard 5. Implementation >
Standard 5C. Consultation
Concept: Professionalism
Feedback
A This is incorrect. It is within the scope of practice of a registered psychiatric
mental health nurse generalist to provide education, case management, and
milieu therapy. The advanced practice psychiatric nurse is authorized to use
psychotherapy to improve mental health. This includes individual, couples,
group, and family psychotherapy.
B This is correct. It is within the scope of practice of a registered psychiatric
C This is incorrect. It is within the scope of practice of a registered psychiatric
D This is incorrect. It is within the scope of practice of a registered psychiatric
PTS: 1 CON: Professionalism
7. A nurse charts “Verbalizes understanding of the side effects of Prozac.” This is an example of
which category of focused charting?
A. Data
B. Problem
C. Action
D. Response
ANS: D
Chapter learning objective: Document client care that validates use of the nursing process.
Page: 182
Heading: Documentation of the Nursing Process > Focus Charting
Integrated Processes: Communication and Documentation
Difficulty: Easy
Feedback
A This is incorrect. “Verbalizes understanding of the side effects of Prozac” is an
example of the response category of focused charting. The response is a
description of the client’s reaction to any part of medical or nursing care.
B This is incorrect. “Verbalizes understanding of the side effects of Prozac” is an
C This is incorrect. “Verbalizes understanding of the side effects of Prozac” is an
D This is correct. “Verbalizes understanding of the side effects of Prozac” is an
8. The nurse should recognize which acronym as representing problem-oriented charting?

A. SOAPIE
B. SOLER
C. DAR
D. PQRST
ANS: A
Page: 181
Heading: Documentation of the Nursing Process > Problem-Oriented Recording
Difficulty: Easy
Feedback
A This is correct. The acronym SOAPIE represents problem-oriented charting,
which reflects the subjective, objective, assessment, plan, implementation, and
evaluation format. This type of charting identifies nursing diagnoses (client
problems) on a written plan of care with appropriate nursing interventions
described for each.
B This is incorrect. The acronym SOLER represents sit squarely, open posture,
lean toward the client, eye contact, and relax. SOLER refers to how the nurse
should use body language to facilitate therapeutic communication.
C This is incorrect. The acronym DAR refers to the data, action, and response
format used in focus charting. The acronym SOAPIE represents
problem-oriented charting, which reflects the subjective, objective, assessment,
plan, implementation, and evaluation format. This type of charting identifies
nursing diagnoses (client problems) on a written plan of care with appropriate
nursing interventions described for each.
D This is incorrect. The acronym SOAPIE represents problem-oriented charting,
which reflects the subjective, objective, assessment, plan, implementation, and
evaluation format. This type of charting identifies nursing diagnoses (client
problems) on a written plan of care with appropriate nursing interventions
described for each.
9. Which tool would be appropriate for a nurse to use when assessing mental acuity prior to and
immediately following electroconvulsive therapy (ECT)?
A. CIWA scale
B. GGT
C. MMSE
D. CAPS scale
ANS: C
Page: 172
Concept: Cognition
Feedback
A This is incorrect. The MMSE, or mini-mental status examination, would be the
appropriate tool to use to assess the mental acuity of a client prior to and
immediately following ECT. The CIWA scale, or clinical institute withdrawal
assessment scale, is used to assess alcohol withdrawal.
B This is incorrect. The MMSE, or mini-mental status examination, would be the
immediately following ECT. The GGT test is used to assess gamma-glutamyl
transferase levels, which may be an indication of alcoholism.
C This is correct. The MMSE, or mini-mental status examination, would be the
immediately following ECT.
D This is incorrect. The MMSE, or mini-mental status examination, would be the
immediately following ECT. The CAPS scale is a clinician-administered scale
for posttraumatic stress disorder (PTSD) and is used to assess signs and
symptoms of PTSD.
PTS: 1 CON: Cognition
10. What is being assessed when a nurse asks a client to identify name, date, residential address,
and situation?
A. Mood
B. Perception
C. Orientation
D. Affect
ANS: C
Page: 169
Concept: Cognition
Difficulty: Easy
Feedback
A This is incorrect. The nurse is assessing the client’s orientation by asking the
client to identify name, date, residential address, and situation. Assessment of
the client’s orientation to reality is part of a mental status evaluation.
B This is incorrect. The nurse is assessing the client’s orientation by asking the
C This is correct. The nurse is assessing the client’s orientation by asking the
D This is incorrect. The nurse is assessing the client’s orientation by asking the
PTS: 1 CON: Cognition
11. Which is the nurse’s purpose when gathering client information?

A. It enables the nurse to modify client behaviors related to personality disorders.
B. It enables the nurse to make sound clinical judgments and plan appropriate client
care.
C. It enables the nurse to prescribe the appropriate medications.
D. It enables the nurse to assign the appropriate Axis I diagnosis.
ANS: B
Page: 166
Feedback
A This is incorrect. The purpose of gathering client information is to enable the
nurse to make sound clinical nursing judgments and plan appropriate care. The
nurse should complete a thorough assessment of the client, including
information collected from the client, significant others, and health-care
providers.
B This is correct. The purpose of gathering client information is to enable the
providers.
C This is incorrect. The purpose of gathering client information is to enable the
providers.
D This is incorrect. The purpose of gathering client information is to enable the
providers.
12. 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?
A. Health teacher
B. Case manager
C. Milieu manager
D. Psychotherapist
ANS: C
Page: 174
Heading: The Nursing Process > Standards of Practice > Standard 5. Implementation >
Standard 5F. Milieu Therapy
Concept: Safety
Difficulty: Difficult
Feedback
A This is incorrect. The nurse’s actions represent the nurse’s role of milieu
manager. The milieu manager implements care by scheduling client activities,
interacting with clients, and maintaining a safe therapeutic environment. The
role of health teacher involves promoting health and a safe environment.
B This is incorrect. The nurse’s actions represent the nurse’s role of milieu
role of the case manager is to organize client care so that outcomes are achieved.
C This is correct. The nurse’s actions represent the nurse’s role of milieu manager.
The milieu manager implements care by scheduling client activities, interacting
with clients, and maintaining a safe therapeutic environment.
D This is incorrect. The nurse’s actions represent the nurse’s role of milieu
role of psychotherapist involves conducting individual, couples, group, and
family counseling.
PTS: 1 CON: Safety
13. The following outcome was developed for a client: “Client will list five personal strengths by
the end of day 1.” Which correctly written nursing diagnostic statement most likely generated
the development of this outcome?
A. Altered self-esteem R/T years of emotional abuse AEB self-deprecating statements
B. Self-care deficit R/T altered thought processes
C. Disturbed body image R/T major depressive disorder AEB mood rating of 2/10
D. Risk for disturbed self-concept R/T hopelessness AEB suicide attempt
ANS: A
Page: 175
Heading: The Nursing Process > Standards of Practice > Standard 6. Evaluation
Cognitive Level: Analysis [Analyzing]
Feedback
A This is correct. The nursing diagnostic statement “Altered self-esteem R/T years
of emotional abuse AEB self-deprecating statements” most likely generated the
outcome of “the client will list five personal strengths by the end of day 1.”
B This is incorrect. The self-care deficit nursing diagnosis is incorrectly written.
The correct nursing diagnostic statement is “Altered self-esteem R/T years of
emotional abuse AEB self-deprecating statements” and most likely generated
the outcome of “the client will list five personal strengths by the end of day 1.”
C This is incorrect. The “risk for disturbed self-concept” nursing diagnosis is
incorrectly written. The correct nursing diagnostic statement is “Altered
self-esteem R/T years of emotional abuse AEB self-deprecating statements” and
most likely generated the outcome of “the client will list five personal strengths
by the end of day 1.”
D This is incorrect. The correct nursing diagnostic statement is “Altered
self-esteem R/T years of emotional abuse AEB self-deprecating statements” and
most likely generated the outcome of “the client will list five personal strengths
by the end of day 1.”
14. How should a nurse prioritize nursing diagnoses?

A. By the established goal of care
B. By the life-threatening potential
C. By the physician’s priority of care
D. By the client’s preference
ANS: B
Page: 178
Heading: Applying the Nursing Process in the Psychiatric Setting
Difficulty: Easy
Feedback
A This is incorrect. The nurse should prioritize nursing diagnoses related to
life-threatening potential. Safety is always the nurse’s priority.
B This is correct. The nurse should prioritize nursing diagnoses related to
C This is incorrect. The nurse should prioritize nursing diagnoses related to
D This is incorrect. The nurse should prioritize nursing diagnoses related to

15. A client has a nursing diagnosis of “Insomnia R/T paranoid thinking AEB midnight
awakenings, difficulty falling asleep, and daytime napping.” Which is a correctly written and
appropriate outcome for this client’s problem?
A. The client will avoid daytime napping and attend all groups.
B. The client will exercise, as needed, before bedtime.
C. The client will sleep 7 uninterrupted hours by day 4 of hospitalization.
D. The client’s sleep habits will improve during hospitalization.
ANS: C
Page: 173
Heading: The Nursing Process > Standards of Practice > Standard 3. Outcomes Identification
Feedback
A This is incorrect. The outcome “The client will sleep 7 uninterrupted hours by
day 4 of hospitalization” is accurately written and is an appropriate outcome.
Outcomes should be measurable, realistic, client-focused goals that include a
time frame. Appropriate nursing interventions are guided by client outcomes.
B This is incorrect. The outcome “The client will sleep 7 uninterrupted hours by
C This is correct. The outcome “The client will sleep 7 uninterrupted hours by day
4 of hospitalization” is accurately written and is an appropriate outcome.
D This is incorrect. The outcome “The client will sleep 7 uninterrupted hours by
16. The following North American Nursing Diagnosis Association (NANDA) nursing diagnostic
stem was developed for a client on an inpatient unit:“Risk for injury.”
Which assessment data most likely led to the development of this problem statement?
A. The client is receiving ECT and is diagnosed with Parkinsonism.
B. The client has a history of four suicide attempts in adolescence.
C. The client expresses hopelessness and helplessness and isolates self.
D. The client has disorganized thought processes and delusional thinking.
ANS: A
Page: 173
Heading: The Nursing Process > Standards of Practice > Standard 2. Diagnosis
Client Need: Physiological
Feedback
A This is correct. The assessment data identifying the client’s confusion and
potential for falls related to Parkinsonism led to the problem statement “risk for
injury.”
B This is incorrect. The assessment data identifying the client’s confusion and
injury.” History of suicide would lead to the development of the nursing
diagnosis “risk for suicide.”
C This is incorrect. The assessment data identifying the client’s confusion and
injury.” The nursing diagnosis “risk for suicide” is appropriate for the client
who is isolating and expressing hopelessness and helplessness.
D This is incorrect. The assessment data identifying the client’s confusion and
injury.” The nursing diagnosis “altered thought processes” is appropriate for the
client with disorganized thought processes and delusional thinking.
17. A student nurse asks an instructor which resource is best to use when developing nursing
outcomes for clients. Which reply most accurately answers the student’s question?
A. “Use the Nursing Interventions Classification (NIC) as a reference for nursing
outcomes.”
B. “Use the NANDA resource to identify appropriate outcomes.”
C. “Use the Nursing Outcomes Classification (NOC) as a reference for nursing
outcomes.”
D. “Copy your standard outcomes from a nursing care plan textbook.”
ANS: C
Chapter learning objective: Use the NANDA resource to identify appropriate outcomes.
Page: 173–174
Feedback
A This is incorrect. The instructor’s reply “Use the Nursing Outcomes
Classification (NOC), as a reference for nursing outcomes” best answers the
student’s question. NOC is a comprehensive, standardized classification of
client outcomes developed to evaluate the effects of nursing interventions.
NANDA is a resource for identifying approved nursing diagnoses.
B This is incorrect. The instructor’s reply “Use the Nursing Outcomes
C This is correct. The instructor’s reply “Use the Nursing Outcomes Classification
(NOC), as a reference for nursing outcomes” best answers the student’s
question. NOC is a comprehensive, standardized classification of client
outcomes developed to evaluate the effects of nursing interventions. NANDA is
a resource for identifying approved nursing diagnoses.
D This is incorrect. The instructor’s reply “Use the Nursing Outcomes
18. A client diagnosed with schizophrenia is exhibiting nonverbal behaviors indicating that the
client is hearing things that others do not. Which nursing diagnosis accurately reflects this
client’s problem?
A. Altered thought processes
B. Altered sensory perception
C. Anxiety
D. Chronic confusion
ANS: B
Page: 173
Feedback
A This is incorrect. Delusional thinking, confusion, and disorientation are
associated with the nursing diagnosis “altered thought processes.” The nursing
diagnosis “altered sensory perception” accurately reflects the client’s symptoms
of hearing things that others do not. A nursing diagnosis describes a client’s
condition and facilitates the prescription of interventions.
B This is correct. The nursing diagnosis “altered sensory perception” accurately
reflects the client’s symptoms of hearing things that others do not. A nursing
diagnosis describes a client’s condition and facilitates the prescription of
interventions.
C This is incorrect. The nursing diagnosis “altered sensory perception” accurately
reflects the client’s symptoms of hearing things that others do not. A nursing
diagnosis describes a client’s condition and facilitates the prescription of
interventions.
D This is incorrect. The nursing diagnosis “altered sensory perception” accurately
reflects the client’s symptoms of hearing things that others do not. Delusional
thinking, confusion, and disorientation are associated with the nursing diagnosis
“altered thought processes.” A nursing diagnosis describes a client’s condition
and facilitates the prescription of interventions.
19. A nursing instructor is teaching students about the purpose of using the nursing process in the
care of psychiatric patients. Which of the following statements by a student indicates learning
has occurred?
A. “The nursing process is a method for interviewing the patient in a systematic way.”
B. “The nursing process is used to assist patients to adapt successfully to stressors
within the environment.”
C. “The nursing process is used to provide support for the psychiatric diagnosis.”
D. “The nursing process is used primarily to minimize allegations of negligence.”
ANS: B
Chapter learning objective: Define nursing process.
Page: 165
Heading: The Nursing Process > Definition
Integrated Processes: Nursing Process: Evaluation
Client Need: Teaching/Learning
Feedback
A This is incorrect. The nursing process is a method for nursing care delivery in
which the patient’s unhealthy responses are identified and interventions to assist
the patient in adapting more successfully to the environment are planned.
B This is correct. The nursing process is a method for nursing care delivery in
C This is incorrect. The nursing process is a method for nursing care delivery in
D This is incorrect. The nursing process is a method for nursing care delivery in
20. A client is diagnosed with Generalized Anxiety Disorder. Which assessment should the nurse
perform to maximize the learning process prior to discharge teaching?
A. Assess the client’s level of anxiety.
B. Assess and document the client’s vital signs.
C. Assess suicide risk.
D. Assess availability of support systems.
ANS: A
Page: 166
Difficulty: Easy
Feedback
A This is correct. The nurse should assess the client’s level of anxiety. Moderate
and high levels of anxiety will interfere with the learning process.
B This is incorrect. The nurse should assess the client’s level of anxiety. Moderate
C This is incorrect. The nurse should assess the client’s level of anxiety. Moderate
D This is incorrect. The nurse should assess the client’s level of anxiety. Moderate
21. During the implementation phase of the nursing process, a nurse is teaching an adult
depressed patient with a cochlear implant about medications. Which modification in the
teaching plan would be best for this client?
A. Using repetition
B. Speaking directly face to face
C. Employing the use of sign language
D. Providing large-print materials
ANS: B
Page: 174
Heading: The Nursing Process > Standards of Practice > Standard 5. Implementation
Difficulty: Easy
Feedback
A This is incorrect. Speaking face to face is the best way to teach individuals with
alterations in hearing.
B This is correct. Speaking face to face is the best way to teach individuals with
C This is incorrect. Speaking face to face is the best way to teach individuals with
D This is incorrect. Speaking face to face is the best way to teach individuals with
22. A client who slept 6 hours the previous night reports it to the assigned psychiatric nurse.
Which should be the initial nursing action to address this situation?
A. Provide warm milk and a backrub.
B. Give a sleep medication.
C. Hold a relaxation group before bedtime.
D. Review the client’s normal sleep pattern.
ANS: D
Page: 166
Feedback
A This is incorrect. The nurse should initially determine the client’s normal sleep
patterns to evaluate whether a problem exists. During the assessment phase of
the nursing process, the nurse collects comprehensive health data pertinent to
the client’s health or situation. Providing warm milk and a backrub are nursing
interventions and occur after the assessment phase.
B This is incorrect. The nurse should initially determine the client’s normal sleep
the client’s health or situation. Administering a sleep medication is a nursing
intervention and occurs after the assessment phase.
C This is incorrect. The nurse should initially determine the client’s normal sleep
the client’s health or situation. Holding a relaxation group before bedtime is a
nursing intervention and occurs after the assessment phase.
D This is correct. The nurse should initially determine the client’s normal sleep
the client’s health or situation.
23. A nursing instructor overhears a student say, “That family seems to disagree more than agree.
The family seems to be dysfunctional.” To further assess the family’s situation, which would
be an appropriate reply by the instructor?
A. “Families who disagree can be a challenge to the treatment team.”
B. “You seem critical of the family. Do you believe that you are unable to help
them?”
C. “Let’s bring the family in for an educational session to improve their
communication.”
D. “What appears to trigger family disagreements?”
ANS: D
Page: 166
Feedback
A This is incorrect. Prior to intervening with this family, the nurse should gather
further information about the cause of family conflicts. Gathering information is
part of the assessment phase of the nursing process, during which the nurse
collects comprehensive health data that are pertinent to the client’s health or
situation.
B This is incorrect. Prior to intervening with this family, the nurse should gather
situation.
C This is incorrect. Prior to intervening with this family, the nurse should gather
situation.
D This is correct. Prior to intervening with this family, the nurse should gather
situation.
24. Which nursing response best represents the evaluation phase of the nursing process?
A. “If I were in your situation, I would not repeat a behavior that has caused
problems.”
B. “What do you think needs changing, and what do you want to do differently?”
C. “What exactly will it take to carry out your plan, and what else do you need to
do?”
D. “It sounds like you’re saying this new approach is working for you.”
ANS: D
Page: 175
Heading: The Nursing Process > Standards of Practice > Standard 6. Evaluation
Integrated Processes: Nursing Process: Evaluation
Client Need: Psychosocial Integrity
Feedback
A This is incorrect. This nursing response represents an implementation. The
nurse’s response “It sounds like you’re saying this new approach is working for
you” best represents the evaluation phase of the nursing process. During the
evaluation phase of the nursing process, the nurse and client evaluate progress
toward attainment of the expected outcomes.
B This is incorrect. This nursing response represents an implementation. The
C This is incorrect. This nursing response represents an implementation. The
D This is correct. The nurse’s statement “It sounds like you’re saying this new
approach is working for you.” best represents the evaluation phase of the
nursing process. During the evaluation phase of the nursing process, the nurse
and the client evaluate progress toward attainment of the expected outcomes.

25. A client diagnosed with Major Depressive Disorder states, “Why should I keep trying to get a
job? I mess up everything I do.” Which correctly written nursing diagnosis best reflects the
content and mood themes in this client’s statement?
A. Hopelessness R/T poor job performance
B. Risk for impaired adjustment R/T inadequate social skills AEB isolation
C. Altered role performance R/T the fear of failure AEB not seeking employment
D. Chronic low self-esteem R/T major depressive disorder AEB self-hatred
ANS: C
Page: 172–173
Feedback
A This is incorrect. The nursing diagnosis “Altered role performance R/T the fear
of failure AEB not seeking employment” best reflects the content and mood
themes in this client’s statement. The client’s statement indicates that role
performance is altered because fear of failure prevents seeking employment.
B This is incorrect. The nursing diagnosis “Altered role performance R/T the fear
of failure AEB not seeking employment” best reflects the content and mood
performance is altered because fear of failure prevents seeking employment. A
“risk for” diagnosis does not contain AEB because there is only a potential for
the problem; it doesn’t yet exist.
C This is correct. This client’s statement indicates role performance is altered
because fear of failure prevents seeking employment. The nursing diagnosis
“Altered role performance R/T the fear of failure AEB not seeking employment”
best reflects the content and mood themes in this client’s statement.
D This is incorrect. The data in this client’s statement does not support the nursing
diagnosis “Altered role performance R/T the fear of failure AEB not seeking
employment.” The nursing diagnosis “Altered role performance R/T the fear of
failure AEB not seeking employment” best reflects the content and mood
performance is altered because fear of failure prevents seeking employment.
26. During an intake interview, which question would best assist the nurse to gather data about
the client’s judgment?
A. “What brought you to the hospital? Do you know what day and season it is now?”
B. “On a scale of 1 to 10, how would you rate your stress level?”
C. “What does the phrase ‘a rolling stone gathers no moss’ mean to you?”
D. “If you found a stamped, addressed envelope in the street, what would you do?”
ANS: D
Page: 166
Feedback
A This is incorrect. The best assessment question is “If you found a stamped,
addressed envelope in the street, what would you do?” Presenting a situation
that requires the client to make a judgment call allows the nurse to assess
appropriate judgment based on the client’s action choice. In the assessment
phase of the nursing process, the nurse collects comprehensive health data that
are pertinent to the client’s health or situation.
B This is incorrect. The best assessment question is “If you found a stamped,
C This is incorrect. The best assessment question is “If you found a stamped,
D This is correct. The best assessment question is “If you found a stamped,
27. An adolescent client has problems expressing anger appropriately. Which nursing statement
would encourage the client to set realistic goals?
A. “What do you think needs to change about how you express anger?”
B. “How did you feel after attending the anger management session?”
C. “On a scale of 1 to 10, please rate your current level of anger.”
D. “What bothers you about the actions of others when you get angry?”
ANS: A
Page: 174
Heading: The Nursing Process > Standards of Practice > Standard 4. Planning
Client Need: Psychosocial Integrity
Difficulty:
Feedback
A This is correct. The nurse’s question “What do you think needs to change about
how you express anger?” encourages the client to set realistic goals. The nurse is
assisting the client to formulate a plan of action. In the planning phase of the
nursing process, the nurse works with the client to identify expected outcomes
for a plan individualized to the client or to the situation.
B This is incorrect. The nurse’s question “What do you think needs to change
about how you express anger?” encourages the client to set realistic goals. The
nurse is assisting the client to formulate a plan of action. In the planning phase
of the nursing process, the nurse works with the client to identify expected
outcomes for a plan individualized to the client or to the situation.
C This is incorrect. The nurse’s question “What do you think needs to change
D This is incorrect. The nurse’s question “What do you think needs to change
28. The nurse interviewed a client who was uncooperative, answered questions with minimal
responses, and rarely made eye contact. Which is the most complete documentation of
baseline data obtained during the interview?
A. “Appears uncooperative. Exhibits characteristics of depression.”
B. “Maintains poor eye contact throughout interview process. Unable to answer
interview questions due to depression.”
C. “States ‘I don’t need to be here’ when discussing admission status. Maintains
minimal eye contact and offers little data related to triggers for admission.”
D. “Unwilling to respond openly during interview.”
ANS: C
Page: 180–181
Heading: Documentation of the Nursing Process
Feedback
A This is incorrect. All charting entries to the client’s legal record should be
objective and based on assessed data. Implications and generalizations should be
avoided. “Appears uncooperative” is a general statement. Documentation occurs
in the implementation phase of the nursing process.
B This is incorrect. All charting entries to the client’s legal record should be
avoided. “Unable to answer interview questions due to depression” implies that
the nurse knows the cause of the client’s behavior. Documentation occurs in the
implementation phase of the nursing process.
C This is correct. All charting entries to the client’s legal record should be
avoided. This statement contains objective data. Documentation occurs in the
implementation phase of the nursing process.
D This is incorrect. All charting entries to the client’s legal record should be
avoided. “Unwilling to respond openly during interview” implies that the nurse
knows the underlying reason for the client’s behavior. Documentation occurs in
the implementation phase of the nursing process.
29. A client is assigned the nursing diagnosis of impaired social interaction R/T sociocultural
differences AEB client stating, “Although I’d like to, I don’t join in because I don’t speak the
language so good.” Which correctly written outcome addresses this client’s problem?
A. The client will collaborate with nursing staff to set specific goals by day 3.
B. The client will participate in one group activity of choice by day 2.
C. The client will express a desire to interact with others.
D. The client will become increasingly independent by discharge.
ANS: B
Page: 173
Feedback
A This is incorrect. This outcome is not directly related to the client’s situation. In
the planning phase of the nursing process, the nurse works with the client to
identify expected outcomes for a plan individualized to the client’s need or to
the situation.
B This is correct. This outcome is directly related to the client’s situation. In the
planning phase of the nursing process, the nurse works with the client to identify
expected outcomes for a plan individualized to the client’s need or to the
situation.
C This is incorrect. This outcome is not directly related to the client’s situation. In
the situation.
D This is incorrect. This outcome is not directly related to the client’s situation. In
the situation.
30. The following clients are seen in the emergency department. The psychiatric unit has one
remaining bed. Which client should the triage nurse expect to be admitted?
A. The client who is experiencing tremors and has a need for medication adjustment
B. The client who is experiencing anxiety and a sad mood after separation from
spouse
C. The client who is a single parent and hears voices stating, “Kill your infant son.”
D. The client who argued with her boyfriend and inflicted a superficial cut on her arm
ANS: C
Page: 166
Difficulty: Easy
Feedback
A This is incorrect. Safety of self and others is always a priority. The nurse’s
assessment indicates the client verbalizing intent to “kill her infant son” is the
greatest safety risk. In the assessment phase of the nursing process, the nurse
situation.
B This is incorrect. Safety of self and others is always a priority. The nurse’s
situation.
C This is correct. The nurse’s assessment indicates this client is at the greatest risk
due to stating an intent to “kill her infant son.” Safety of self and others is
always a priority. In the assessment phase of the nursing process, the nurse
situation.
D This is incorrect. Safety of self and others is always a priority. The nurse’s
situation.
MULTIPLE RESPONSE
31. Which of the following nursing interventions fall within the standards of psychiatric-mental
health clinical nursing practice for a nurse generalist? Select all that apply.
A. Assist clients to perform activities of daily living.
B. Act as a consultant with other clinicians to provide services for clients and effect
system change.
C. Encourage clients to discuss triggers for relapse.
D. Use prescriptive authority in accordance with state and federal laws.
E. Educate families about signs and symptoms of alcohol dependence and
withdrawal.
ANS: A, C, E
Page: 165
Heading: The Nursing Process > Standards of Practice
Concept: Professionalism
Feedback
1. This is correct. Assisting clients to perform activities of daily living, encouraging
clients to discuss triggers, and educating families are nursing interventions that fall
within the standards of psychiatric clinical nursing practice for a nurse generalist.
2. This is incorrect. This does not fall within the standards of psychiatric clinical
nursing practice for a nurse generalist. Assisting clients to perform activities of daily
living, encouraging clients to discuss triggers, and educating families are nursing
interventions that fall within the standards of psychiatric clinical nursing practice for
a nurse generalist.
4. This is incorrect. This does not fall within the standards of psychiatric clinical
nursing practice for a nurse generalist. Assisting clients to perform activities of daily
living, encouraging clients to discuss triggers, and educating families are nursing
interventions that fall within the standards of psychiatric clinical nursing practice for
a nurse generalist.
PTS: 1 CON: Professionalism
32. Which of the following are characteristics of accurately developed client outcomes? Select all
that apply.
A. Client outcomes are formulated by each nurse independent of other team members.
B. Client outcomes are not restricted by time frames.
C. Client outcomes are specific and measurable.
D. Client outcomes are realistically based on client capability.
E. Client outcomes are formally approved by the psychiatrist.
ANS: C, D
Page: 173
Cognitive Level: Comprehension
Feedback
1. This is incorrect. Outcomes are most effective when formulated cooperatively by the
interdisciplinary team members, client, and significant others.
2. This is incorrect. Outcomes should be derived from the diagnosis and should include
a time estimate for attainment.
3. This is correct. Client outcomes should be specific, measurable, and realistically
based on client capability.
4. This is correct. Client outcomes should be specific, measurable, and realistically
based on client capability.
5. This is incorrect. The psychiatrist does not formulate outcomes independent of other
interdisciplinary team members. Outcomes are most effective when formulated
cooperatively by the interdisciplinary team members, client, and significant others.

33. After a comprehensive assessment, correctly written nursing diagnoses developed for
psychiatric clients may include which of the following components? Select all that apply.
A. Medical judgments related to the psychiatric disorder
B. Unmet client needs present at the moment
C. Supporting data that validate the diagnosis
D. Outcomes that will be targets for nursing interventions
E. Statements of client problems of a functional nature
ANS: B, C, E
Page: 173
Feedback
1. This is incorrect. A nursing diagnosis is a statement of a client’s functional problem.
An actual nursing diagnosis must include related to (R/T) and as evidenced by
(AEB) statements.
2. This is correct. A nursing diagnosis is a statement of a client’s functional problem.
(AEB) statements.
(AEB) statements.
4. This is incorrect. A nursing diagnosis is a statement of a client’s functional problem.
(AEB) statements.
(AEB) statements.

Psychiatric Mental Health Nursing Concepts of Care in Evidence Based Practice 9th Edition Townsend Test Bank

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Psychiatric Mental Health Nursing Concepts of Care in Evidence Based Practice 9th Edition Townsend Test Bank

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Psychiatric Mental Health Nursing

Concepts of Care in Evidence Based

PTS: 1 CON: Communication

PTS: 1 CON: Patient-Centered Care

3. Which nursing diagnosis should a nurse identify as being correctly formulated?

PTS: 1 CON: Patient-Centered Care

PTS: 1 CON: Patient-Centered Care

5. Which statement regarding nursing interventions should a nurse identify as accurate?

PTS: 1 CON: Patient-Centered Care

PTS: 1 CON: Professionalism

PTS: 1 CON: Communication

8. The nurse should recognize which acronym as representing problem-oriented charting?

PTS: 1 CON: Communication

PTS: 1 CON: Cognition

PTS: 1 CON: Cognition

11. Which is the nurse’s purpose when gathering client information?

PTS: 1 CON: Patient-Centered Care

PTS: 1 CON: Safety

PTS: 1 CON: Patient-Centered Care

14. How should a nurse prioritize nursing diagnoses?

PTS: 1 CON: Patient-Centered Care

PTS: 1 CON: Communication

PTS: 1 CON: Patient-Centered Care

PTS: 1 CON: Patient-Centered Care

PTS: 1 CON: Patient-Centered Care

PTS: 1 CON: Patient-Centered Care

PTS: 1 CON: Patient-Centered Care

PTS: 1 CON: Patient-Centered Care

PTS: 1 CON: Patient-Centered Care

PTS: 1 CON: Patient-Centered Care

PTS: 1 CON: Communication

PTS: 1 CON: Patient-Centered Care

PTS: 1 CON: Patient-Centered Care

PTS: 1 CON: Patient-Centered Care

PTS: 1 CON: Communication

PTS: 1 CON: Communication

PTS: 1 CON: Patient-Centered Care

PTS: 1 CON: Professionalism

PTS: 1 CON: Patient-Centered Care

PTS: 1 CON: Patient-Centered Care

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