Test Bank For Psychiatric Mental Health Nursing - Revised Reprint, 5th Edition - Exam Guides | Nursing

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Chapter 01: Psychiatric Nursing: Theory,Principles, and TrendsFortinash: Psychiatric Mental Health Nursing, 5th EditionChapter 01: Psychiatric Nursing: Theory, Principles, and TrendsTest BankMULTIPLE CHOICE1. Which understanding is the basis for the nursing actions focused on minimizingmental health promotion of families with chronically mentally ill members?a.Familymembersareatanincreasedriskformentalillness.b.Thementalhealthcaresystemisnotpreparedtodealwithfamilycrises.c.Familymembersareseldompreparedtocopewithachronicallyillindividual.d.Thechronicallymentallyillreceivecarebestwhendeliveredinaformalsetting.ANS: AWhen families live with a dominant member who has a persistent and severe mentaldisorder the outcomes are often expressed as family members who are at increasedrisk for physical and mental illnesses. The remaining options are not necessarily true.DIF: Cognitive Level: Application REF: Page 3 TOP: Nursing Process: PlanningMSC: NCLEX: Psychosocial Integrity, Health Promotion and Maintenance2. Which nursing activity shows the nurse actively engaged in the primary preventionof mental disorders?a.Providingapatient,whosedepressioniswellmanaged,withmedicationontimeb.Makingregularfollow-upvisitstoanewmotheratriskforpost-partumdepressionc.Providingthefamilyofapatient,diagnosedwithdepression,informationonsuicidepreved.AssistingapatientwhohasobsessivecompulsivetendenciesprepareandpracticeforajobANS: BPrimary prevention helps to reduce the occurrence of mental disorders by stayinginvolved with a patient. Providing medication and information on existing illnessesare examples of secondary prevention which helps to reduce the prevalence of mentaldisorders. Assisting a mentally ill patient with preparation for a job interview istertiary prevention since it involves rehabilitation.DIF: Cognitive Level: Application REF: Page 4TOP: Nursing Process: Implementation

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MSC: NCLEX: Psychosocial Integrity, Health Promotion and Maintenance3. Which intervention reflects attention being focused on thepatient’sintentionsregarding his diagnosis of severe depression?a.Beingplacedonsuicideprecautionsb.Encouragingvisitsbyhisfamilymembersc.Receivingacombinationofmedicationstoaddresshisemotionalneedsd.BeingaskedtodecidewherehewillattendhisprescribedtherapysessionsANS: DA primary factor in patient treatment includes consideration of thepatient’sintentionsregarding his or her own care. Patients are central to the process that determines theircare as their abilities allow. Under the guidance of PMH nurses and other mentalhealth personnel, patients are encouraged to make decisions and to actively engage intheir own treatment plans to meet their needs. The remaining options are focused onspecifics of the determined plan of care.DIF: Cognitive Level: Application REF: Page 5TOP: Nursing Process: ImplementationMSC: NCLEX: Psychosocial Integrity, Health Promotion and Maintenance4. When apatient’sfamily asks why their chronically mentally ill adult child is beingdischarged to a community-based living facility, the nurse responds:a.“Itisawaytomeettheneedforsocialsupport.”b.“Itistooexpensivetokeepstabilizedpatientsinacutecaresettings.”c.“Thistypeoffacilitywillprovidethespecializedcarethatisneeded.”d.“Beingoutinthecommunitywillhelpprovidehopeandpurposeforliving.”ANS: DHospitalization may be necessary for acute care, but, when patients are stabilized,they move into community-based, patient-centered settings or are discharged homewith continued outpatient treatment in the community. Concentrated efforts are madeto reduce thepatient’ssick role by providing opportunities for the development of apurposeful life and instilling hope for eachpatient’sfuture. Although social support isimportant, such a living arrangement is not the only way to achieve it. Although acutecare is expensive, it is not the major concern when determining long-term careoptions. Community-based facilities are not the only option for specialized care.

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DIF: Cognitive Level: Application REF: Page 5TOP: Nursing Process: ImplementationMSC: NCLEX: Psychosocial Integrity, Health Promotion and Maintenance5. What is the best explanation to offer when the mother of a chronically ill teenagepatient asks,“Underwhat circumstances would he be consideredincompetent?”a.“Whenyoucanprovidethecourtwithenoughevidencetoshowthatheisnotabletocaresafely.”b.“Itisnotlikelythatsomeonehisagewouldbedeterminedtobeincompetentregardlessofcondition.”c.“Hewouldhavetoengageinbehaviorthatwouldresultinharmtohimselfortosomeoneehissiblings.”d.“Iftheillnessbecomessoseverethathisjudgmentisimpairedtothepointwherethedecisareharmfultohimselfortoothers.”ANS: DWhen a person is unable to cognitively process information or to make decisionsabout his or her own welfare, the person may be determined to be mentallyincompetent. Providing self-care is not the only criteria considered. Age is not a factorconsidered. The decision is often based on the potential for such behavior.DIF: Cognitive Level: Application REF: Page 6TOP: Nursing Process: ImplementationMSC: NCLEX: Safe, Effective Care Environment: Management of Care,Psychosocial Integrity6. Which psychiatric nursing intervention shows an understanding of integrated care?a.Achronicallyabusedwomanisassessedforanxiety.b.Amanicpatientistakentothegymtousetheexerciseequipment.c.Theolderadultdiagnosedwithdepressionismonitoredforsuicidalideations.d.Ateenagerwhorefusestoobeytheunit’srulesisnotallowtoplayvideogames.ANS: AThe majority of health disciplines now recognize that mental disorders and physicalillnesses are closely linked. The presence of a mental disorder increases the risk forthe development of physical illnesses and vice versa. Assessing a chronically abusedindividual for anxiety call should attention to the psychiatric disorder that could

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develop from the abuse. The remaining options show interventions that areappropriate for the mental disorder.DIF: Cognitive Level: Application REF: Page 6TOP: Nursing Process: ImplementationMSC: NCLEX: Safe, Effective Care Environment: Management of Care,Psychosocial Integrity7. What reason does the nurse give the patient for the emphasis and attention beingpaid to the recovery phase of their treatment plan?a.Recoverycare,evenwhenintensive,islessexpensivethanacutepsychiatriccare.b.Effectiverecoverycareislikelytoresultinfewerrelapsesandsubsequenthospitalizationsc.Planningforrecoverycareistimeconsumingandinvolvesdealingwithmanycomplicatedd.RecoverycareisusuallydoneonanoutpatientbasisandsoisgenerallybetteracceptedbyANS: BMuch attention is paid to recovery care since effective recovery care helps improvepatient outcomes and thus minimize subsequent hospitalizations. Recovery care is notnecessarily less expensive than acute care. Although effective recovery care planningmay 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 7TOP: Nursing Process: ImplementationMSC: NCLEX: Safe, Effective Care Environment: Management of Care,Psychosocial Integrity8. The nurse is attending a neighborhood meeting where a half-way house is beingproposed for the neighborhood when a member of the community states,“Wedon’twant the facility; we especiallydon’twant violent people living near us.”Theresponse by the nurse that best addresses thepublic’sconcern is:a.“Intruth,mostindividualswithpsychiatricdisorderarepassiveandwithdrawnandposelithosearoundthem.”b.“Thementallyillseldombehaveinthemannertheyareportrayedbymovies;theyarepeoprestofus.”c.“Patientswithpsychiatricdisorderaresowellmedicatedthattheydonotdisplayviolentbd.“Thementallyilldeserveasafe,comfortableplacetoliveamongpeoplewhotrulycarefoANS: A

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A major reason for the existence of the stigma placed on persons with mental illness islack of knowledge. The main fear is of violence, although only a small percentage ofpatients with mental illness display this behavior. Providing the public with accurateinformation can help reduce stigma. The remaining options do not directly address theconcerns stated.DIF: Cognitive Level: Application REF: Pages 13-14TOP: Nursing Process: ImplementationMSC: NCLEX: Safe, Effective Care Environment: Management of Care,Psychosocial Integrity9. Which activity shows that a therapeutic alliance has been established between thenurse and patient?a.Thenurserespectsthepatient’srighttoprivacywhenvisitorsarespendingtimewiththepb.Thepatientiseagerlyattendingallgroupsessionsandworkingindependentlyonidentifyinstressors.c.Thepatientisfreelydescribingtheirfeelingsrelatedtothephysicalandemotionaltraumaasachildwiththenurse.d.Thenursedutifullyadministersthepatient’smedicationsontimeandwithappropriateknopotentialsideeffects.ANS: CA primary aspect of working with patients in any setting and particularly in thepsychiatric setting is the development of a therapeutic alliance with the patient. Suchan alliance is established on trust. It is a professional bond between the nurse and thepatient that serves as a vehicle for patients to freely discuss their needs and problemsin the absence of thenurse’scriticism or judgment. Any nurse has an obligation torespect thepatient’srights and administer care effectively. Thepatient’swillingnessto participate in the plan of care reflects self motivation.DIF: Cognitive Level: Application REF: Page 9TOP: Nursing Process: ImplementationMSC: NCLEX: Safe, Effective Care Environment: Management of Care,Psychosocial Integrity10. Mental health care reform has called for parity between psychiatric and medicaldiagnoses. Which is an example of such parity?a.Depressiontreatmentisnotpaidforasreadilyasistreatmentforasthma.

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b.Thementallyillpatientwillbeprotectedbylawagainstsocialstigma.c.Medicalpractitionersaretrainedtobeproficientattreatingmentaldisorders.d.Psychiatricservicereimbursementwillbeequivalenttothatofmedicalservices.ANS: DThe termparityas used here refers to payments for mental health services that equalpayment schedules for medical or surgical conditions. The remaining options(B andC) do not relate to financial reimbursement or funds allocated for mental health carebeing equal to those of medical diagnoses.DIF: Cognitive Level: Application REF: Page 15TOP: Nursing Process: ImplementationMSC: NCLEX: Safe, Effective Care Environment: Management of Care,Psychosocial IntegrityMULTIPLE RESPONSE1. Which assessment findings suggest to the nurse that this patient has characteristicsseen in an individual who has reached self-actualization? Select all that apply.a.Reportstohave,“foundpeaceandsecurityinmyreligiousfaith”b.Effectively“changedoccupations”whenachronicvisionproblemworsenedc.Hasconsistentlyearnedasix-figuresalaryasanarchitectforthelast10yearsd.Hasbeeninasupportive,lovingrelationshipwiththesameindividualfor15yearse.Providesfreeliteracytutoringhelpatthelocalhomelessshelter3eveningsaweekANS: A, B, D, ECharacteristics of self actualization would include: spiritual well-being, open andflexible, relationally fulfilled, and generosity toward others. Salarydoesn’tnecessarilyreflect self-actualization.DIF: Cognitive Level: Application REF: Page 4TOP: Nursing Process: AssessmentMSC: NCLEX: Psychosocial Integrity, Health Promotion and Maintenance2. Which nursing activities represent the tertiary level of mental health care? Select allthat apply.a.Providingadepressionscreeningatalocalcollegeb.Helpingamental-challengedpatientlearntomakecorrectchangec.Reportinganincidenceofpossibleelderabusetotheappropriatelegalagency

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d.Regularlyassessingapatient’sunderstandingoftheirprescribedantidepressantse.Providinga6-weekparentingclasstoteenageparentsthroughalocalhighschoolANS: B, DTertiary prevention reduces the residual effects of the disorder such as depression andmental retardation. There is no quaternary level of prevention. Primary preventionreduces occurrences of mental disorders such as screenings and parenting classes, andsecondary prevention reduces the prevalence of disorders as evidenced by assessingknowledge.DIF: Cognitive Level: Application REF: Page 4 TOP: Nursing Process: PlanningMSC: NCLEX: Psychosocial Integrity, Health Promotion and Maintenance3. Which nursing actions indicate an understanding of the priority issues currentlyfacing psychiatric mental health nursing today? Select all that apply.a.Workingonthefacility’s‘SafeUseofRestraintsPolicy’revisioncommitteeb.Advocatingforincreasedsalariesforalllevelsofpsychiatricmentalhealthnursesc.Attendingapoliticalrallyforincreasedstatefundingformentalhealthserviceprovidersd.Offeringanin-servicetofacilitystaffregardingtheculturalimplicationsofcaringfortheHe.JoiningthestatenursingcommitteeworkingontheroleandscopeofpracticeoftheadvanpsychiatricnurseANS: A, C, D, EPriority issues include funding, safety issues in psychiatric treatment centers—particularly the use of patient restraints, quality-of-care issues, access to health carefor minority populations, and standardization of advanced practice nurse roles.DIF: Cognitive Level: Application REF: Page 9TOP: Nursing Process: ImplementationMSC: NCLEX: Safe, Effective Care Environment: Management of Care,Psychosocial Integrity4. Which assessment findings describe risk factors that increase the potential risk formental illness? Select all that apply.a.Possesseshightoleranceforstressb.Isverycuriousabout‘howthingswork’c.Admitstobeingamemberofanethnicgangd.OnlypracticingJewamongschoolclassmates

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e.HasayoungersiblingwhoismentallychallengedANS: C, D, ERisk factors are internal predisposing characteristics and external influences thatincrease aperson’svulnerability and potential for developing mental disorders. Typesof risk factors and examples include the following: having a mentally-challengedfamily member in the home; belonging to a punitive gang; and being the object ofreject or bullying. The remaining options are protective factors.DIF: Cognitive Level: Application REF: Page 11 TOP: Nursing Process: EvaluationMSC: NCLEX: Psychosocial Integrity5. Which nursing actions show a focus on the fundamental goals that guide psychiatricmental health nurses in providing patient care? Select all that apply.a.Offeringaninformationalsessionofidentifyingsignsofdepressionatalocalseniorcenterb.Attendingaworkshoponevidencepracticeinterventionsforthechronicallydepressedpatc.Keepingstrictbutappropriateboundarieswithapatientdiagnosedwithapersonalitydisord.Askingaparentwhohasjustexperiencedthedeathofachildiftheycouldconsidertalkingcounselore.IdentifyingwhathelpapatientdiagnosedwithAlzheimer’sdiseasewillneedwithinstrumdailyliving(IADLs)ANS: A, B, D, EStandard objectives guide PMH nurses and members of related disciplines in the careof patients (individuals, families, communities, and organizations). The objectives andcriteria are as follows: the promotion and protection of mental health, the preventionof 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 3TOP: Nursing Process: Implementation MSC: NCLEX: Physiological IntegrityChapter 02: Nursing Practice in the ClinicalSettingFortinash: Psychiatric Mental Health Nursing, 5th EditionChapter 02: Nursing Practice in the Clinical SettingTest BankMULTIPLE CHOICE

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1. Which nursing action is a reflection of HildegardPeplau’stheoretic frameworkregarding psychiatric mental health nursing?a.Basingpatientoutcomesonexpectedinstinctualresponsesb.Discussingapatient’sfeelingsregardingparentsandsiblingsc.Providingthepatientwithcleanclothesandwholesomefoodd.CenteringprofessionalpracticeinastaterunpsychiatricfacilityANS: BPeplau’spioneering endeavors and contributions were largely influenced byinterpersonal psychotherapy. She believed that disorders evolved in the social contextof interpersonal interactions. (i.e., what went on between people). Instinctualresponses are more related to intrapersonal interactions. Florence Nightingale wasinstrumental in the holistic approach to nursing care, whereas LindaRichards’practice was centered on institutional care of the mental ill.DIF: Cognitive Level: Application REF: Page 18TOP: Nursing Process: ImplementationMSC: NCLEX: Safe, Effective Care Environment, Psychosocial Integrity2. The nurse is attempting to provide a safe environment for a patient at great risk forself-harm. Which intervention shows an understanding of evidence-based practice(EBP)?a.Usingphysicalrestraintsonlyafterallotheroptionshavebeenprovenineffectiveb.Referringtothefacility’spoliciesmanualforguidelinesforapplyingphysicalrestraintsc.Collectingdataregardingtheshort-termeffectsofusingphysicalrestraintsonanaggressivd.Requiringconstantmonitoringofapatientwhoseinabilitytoself-regulateangerhasrequirphysicalrestraintsANS: BHealth care systems are participating in the shift in nursing practice by encouragingresearch in their facilities and by implementing interventions that increasenurses’knowledge about EBP. Nurses are participating to make evidence-based nursingpractices available for their use, and they are helping to determine the outcomes thatwill benefit patients. The remaining options are examples of long-standing practicerelated to the use of physical restraints.DIF: Cognitive Level: Application REF: Page 19TOP: Nursing Process: Implementation

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MSC: NCLEX: Safe, Effective Care Environment, Psychosocial Integrity3. Which statement by the patient reflects patient education that was based on theconcept of integrated patient care?a.“IknowI’manxiouswhenIgetatensionheadache.”b.“MyanxietyisaresultofstressorsIdon’tcopewellwith.”c.“Medicationhashelpedmetremendouslywithanxietycontrol.”d.“Anxietyrunsinmyfamily;myentirefamilyistryingtodealwithit.”ANS: AIntegrated patient care is the recognition of the interplay between physical and mentalhealth. In integrated care, these disorders are not treated as separate illnesses; rather,they are treated together. The remaining options make no mention of a relationshipbetween mental and physical illness.DIF: Cognitive Level: Application REF: Page 19 TOP: Nursing Process: EvaluationMSC: NCLEX: Psychosocial Integrity4. The nurse demonstrates objective patient care when:a.Beingsympathetictothepatient’srecentlossofaspouseb.Protectingtheanxiouspatientbyeliminatingstressorsinthemilieuc.Respondingtothepatientbystating,“Iknowexactlyhowyoufeel.”d.Facilitatingthepatient’sexplorationofvariousstressreductiontechniquesANS: DThe nurse demonstrates objectivity by helping the patient to process and organizethoughts that are directed toward the solving of his or her own problems. Withsympathy, 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- 22TOP: Nursing Process: ImplementationMSC: NCLEX: Safe, Effective Care Environment: Management of Care,Psychosocial Integrity5. Which nursing intervention would be appropriately addressed during the orientationphase of the nurse–patient relationship?a.Selfreflectionbythenurseregardingpersonalbiasesandprejudicesregardingthepatientb.Patientworksatprioritizingpersonalneedsanddevelopsrealisticexpectedoutcomes

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c.Establishingthecontractbetweenthenurseandthepatientregardingmutualneedsandexpd.PatientcommitstothereinforcementofpositivepersonalcharacteristicswhileworkingonconcernsANS: CA 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. SelfReflection occurs during the pre-orientation phase while the remaining options areaddressed during the working phase of the relationship.DIF: Cognitive Level: Analysis REF: Page 22 TOP: Nursing Process: PlanningMSC: NCLEX: Safe, Effective Care Environment: Management of Care,Psychosocial Integrity6. Which action on the part of a novice psychiatric mental health nurse shows a needfor future development of altruism?a.Excusingapatientfromattendinggroupbecause,“allthattalkingmakesmesoanxious”b.Notpermittingtwopatientswhoarephysicallyattractedtoeachothertoengageinpublicdaffectionc.Placingaphysicallyaggressivepatientinrestraintswhentheyareunabletointernallycalmd.Self-reflectingon“whyIcontinuetoworkwithpatientswhoaresoemotionallydamagedbenormal”ANS: AThis option shows a misguided kindness that will ultimately have a negative impacton thepatient’streatment. The remaining options show responsible nursinginterventions that include self-reflection of personal motivation for such work.DIF: Cognitive Level: Application REF: Page 24 TOP: Nursing Process: EvaluationMSC: NCLEX: Safe, Effective Care Environment: Management of Care,Psychosocial Integrity7. The greatest negative outcome resulting from anurse’sfear of a mentally ill patientis that the:a.Nursewillreinforcenegativestereotypingofthementallyill.b.Patientwillexperienceincreasedbiasagainstthenursingstaff.c.Public’sfearfulnessofthementallyillwillcontinuetobeexaggerated.d.Therapeuticalliancebetweenthenurseandpatientwillnotdevelopeffectively.ANS: D

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Unrealistic preconceived images, stereotyping, and biases have an effect on nursesthat, when resulting in fear, will negatively impact the therapeutic effectiveness of thenurse and the care provided. The remaining options do not have the priority thatproviding quality patient care has.DIF: Cognitive Level: Application REF: Page 26TOP: Nursing Process: AssessmentMSC: NCLEX: Safe, Effective Care Environment: Management of Care,Psychosocial Integrity8. Which action on the part of a novice mental health nurse will best minimize fearrelated to effectively working with the psychotic patient?a.Beknowledgeableaboutpsychotropicmedicationsandtheiraffectonpsychosis.b.Alwaysarrangeforstaffsupportwhenworkingone-on-onewithapsychoticpatient.c.Takeadvantageofopportunitiestoattendworkshopsdevotedtothecareofthepsychoticpd.Recognizethatthepsychoticpatientisnotincontroloftheirbehaviorsduetotheiralteredprocesses.ANS: CFear breeds avoidance, but knowledge and preparation diminish fear and bringconfidence. Being prepared before entering the psychiatric setting includes havingknowledge and understanding of mental disorders. The remaining options do notprovide confidence but rather means of controlling or avoiding the psychotic patient.DIF: Cognitive Level: Analysis REF: Page 26TOP: Nursing Process: ImplementationMSC: NCLEX: Safe, Effective Care Environment: Management of Care,Psychosocial Integrity9. Which response by the nurse manager to a novice mental health nurse is mosteffective when the nurse asks,“Howdo I justify not keeping apatient’ssecret?”a.“Neverpromisethepatientthatyouwillkeepasecretforthem.”b.“Alwaysstopthepatientfromtellingyousomethingasasecret.”c.“Letthepatientknowthatyouwillnotkeepasecretthatcouldultimatelycauseharmoraftreatment.”d.“Keepremindingyourselfthatyouarenotthepatient’sfriendbutratheraprofessionalmeprovider.”ANS: C

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Nurses and other healthcare professionals do not keep secrets or make promises topatients when the secret may interfere with thepatient’streatment or put them orothers at risk for harm. The remaining options offer appropriate nursing actions but donot effectively answer thenurse’squestion.DIF: Cognitive Level: Analysis REF: Page 30TOP: Nursing Process: ImplementationMSC: NCLEX: Safe, Effective Care Environment, Psychosocial Integrity10. The nurse is effectively facilitating the nurse-patient relationship when:a.Sharingwithanangrypatientwhoisverballyabusivethat,“AlthoughIcanacceptthatyoucannotandwillnotacceptyourverbalabuse.”b.Focusingonthepatient’slifeexperiencewithoutrelatingtothesimilaritiesofone’sownec.Objectivelyprovidingconstructivecriticismthatisdirectedtohelpingthepatientidentifybehaviorsd.RefrainingfromabandoningthepatientregardlessofthefrustrationtheinteractioncausesANS: AAccepting thepatient’sfeelings is essential; however, it is not necessary to accept allof thepatient’sbehaviors. Assist the patient bysetting limits on patient behaviors thatare self-defeatingor that threaten the patient or others in any way. Setting these limitsallows for mutual respect in the therapeutic alliance. The remaining options enhancethepatient’sclinical experience rather than the nurse-patient relationship.DIF: Cognitive Level: Application REF: Page 35TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity11. An often expressed intrinsic reward of psychiatric mental health nursing is:a.Seeingtheseriouslyillrecovertheirhealthb.Workingwithpatientsofallagesandwalksoflifec.Workingwithwell-trained,caringhealthcareprovidersd.HavingtimetoreallyfocusonthehumanwhoisthepatientANS: DPsychiatric mental health nurses are able to spend the time to know the patient notonly as a patient but as an individual. This is an opportunity most nurses whosepractice is based on the physical care of the patient is not afforded. The remainingoptions are not necessarily unique to psychiatric nursing.DIF: Cognitive Level: Application REF: Page 36 TOP: Nursing Process: Evaluation

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MSC: NCLEX: Psychosocial Integrity12. Which statement is an example of an inference?a.“Heisanalcoholicbecausehiswifenagsalot.”b.“Hestateshebingesafterarguingwithhiswife.”c.“Yousayyouralcoholintakeexceedsaquartaday.”d.“Soyouaresayingthatyouweredrinkingearliertoday.”ANS: AAn inference is an interpretation of behavior that is made by finding motive andforming conclusions without having all the necessary information. The nurseinterprets thepatient’sbehavior, decides on a reason, assigns a motive, and forms aconclusion. The remaining options are validations of observations.DIF: Cognitive Level: Application REF: Page 34TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial IntegrityMULTIPLE RESPONSE1. Which interactions are likely outcomes of a well-established therapeutic alliance?Select all that apply.a.Thenursestates,“I’mnotheretojudgebutrathertohelp.”b.Thepatientstates,“IreallythinkIcanhandlethisproblemnow.”c.Thepatientaskshisabusivefathertoattendcounselingwithhim.d.Thenursesetsboundariesforapatientwhohasfewsocialskills.e.Thepatientwithangerissuesvoluntarilygoesintotheseclusionroom.ANS: A, B, C, EThe alliance serves as a vehicle that provides patients with an opportunity to freelydiscuss their needs and problems in the absence of judgment and criticism, to gaininsight into their abilities, to practice new coping skills, and to heal emotionalwounds. Setting boundaries is not an outcome of such an alliance.DIF: Cognitive Level: Application REF: Page 19TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity2. Which nursing interventions are directly related to the principles on which atherapeutic alliance is based? Select all that apply.a.Graciouslydecliningto,“ComevisitwhenIgetdischarged.”b.Establishingthetopictobediscussedateachgroupsession

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c.Explainingtothepatientthepurposeofterminatingtheallianced.Sharinghowthenursealsohasexperiencedthesameproblemse.Providingsubjectivefeedbacktothepatient’seffortsattherapyANS: A, B, CThe principles that focus on the development and maintenance of a healthy allianceinclude: the relationship is therapeutic rather than social; the focus remains on thepatient’sneeds and problems rather than on the nurse; the relationship is purposefuland goal directed; the relationship is objective rather than subjective in quality; andthe relationship is time-limited rather than open-ended. The sharing of experiencing isnot patient centered.DIF: Cognitive Level: Application REF: Page 20TOP: Nursing Process: ImplementationMSC: NCLEX: Safe, Effective Care Environment: Management of Care3. The nurse is attempting to minimize thegroup’sdisplay of resistance during atherapy session. Which patients are at risk for displaying such behavior? Select all thatapplya.Thepatientwhoiscognitivelyimpairedb.Thepatientwhoisolderandwelleducatedc.Thepatientwhoisaggressiveandattentionseekingd.Thepatientwhohasattendedsimilartherapygroupsinthepaste.ThepatientwhohasbeendiagnosedwithparanoidschizophreniaANS: A, D, EA patient who redirects the focus away from himself or herself by changing thesubject is engaging in resistance behavior. Patients divert the topic for one or more ofseveral reasons: a fear of being judged; avoiding the repetition of material that hasbeen previously discussed; or the inability to stay cognitively focused. The attention-seeking patient may attempt to monopolize the discussion but not necessarily be atrisk for resisting the topic. Age and education are not risk factors.DIF: Cognitive Level: Application REF: Pages 20-21TOP: Nursing Process: AssessmentMSC: NCLEX: Safe, Effective Care Environment: Management of Care,Psychosocial Integrity

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Chapter 03: The Nursing Process andStandards of PracticeFortinash: Psychiatric Mental Health Nursing, 5th EditionChapter 03: The Nursing Process and Standards of PracticeTest BankMULTIPLE CHOICE1. The patient asks the nurse,“I’veheard the student nurses talk about the nursingprocess. Why is there so much emphasis on using the nursingprocess?”The responsethat explains the need for nurses to understand and use the nursing process is:a.“Doyouthinkyouhaveabettermethodwemightuse?”b.“Thenursingprocessisasystematicproblem-solvingmethodencompassingallcomponencareforpatients.”c.“Usingthenursingprocessisawayoflegitimizingourprofessionandplacingusonaneqthepuresciences.”d.“Thenursingprocessisaunidimensional,static,linearapproachusedtoguidenursesasthjudgments.”ANS: BThis response best explains the importance of the nursing process by description andrelationship to patient care. Suggesting that the patient may have a better method ischallenging and does not address the question posed by the patient. Providinglegitimacy to the profession is a very limited explanation for use of the nursingprocess. The nursing process is not one-dimensional, static, or linear.DIF: Cognitive Level: Knowledge REF: Page 40TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective CareEnvironment2. When preparing to conduct a nursing history and assessment on a patienttransferred from the emergency department (ED) whose family believes the patient tobe a questionable historian due to cognitive impairment, the nurse initially begins theinterview by:a.ReviewingtheEDchartb.Contactingtheadmittingphysicianc.Directingthequestionstothefamilymembers

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d.EstablishingalineofcommunicationwiththepatientANS: DThe nurse should begin establishing the nurse–patient relationship by initiallydirecting the questions to the patient. The nurse can confirm information and/or obtainsupplementary information from the sources identified by the other options.DIF: Cognitive Level: Application REF: Page 40TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective CareEnvironment3. The nurse shows the ability to effectively state a nursing diagnosis reflective of theimplications of depression on apatient’slife processes when stating in thepatient’splan of care that:a.Patientoutcomeswerepartiallyattained.Implementationofpresentplantocontinue.b.Patientwillinitiateandsupportconversationwithnursetherapistby(date3weeksinfuturc.Oralmedicationforanxietyshouldbeadministeredwhendepressionisassessedtobeatthd.Impairedverbalcommunicationr/timpoverishedthoughtssecondarytodepressionasevidmonosyllabicresponses.ANS: DThis statement contains the various components of a nursing diagnosis whileexpressing the existence of an altered life process. The remaining options reflect othersteps, such as evaluation and intervention planning.DIF: Cognitive Level: Application REF: Pages 47-48 TOP: Nursing Process: AnalysisMSC: NCLEX: Safe and Effective Care Environment4. When engaging in outcomes identification, the nurse:a.Interviewsandcollectspatient-focuseddatab.Re-assessesthepatient’sphysicalandemotionalstatusevaluationc.Reviewsthepatient’sexistingproblemsandprojectstheresultsofthenursingcared.Considersthepatient’spresentingsymptomsandidentifiesnursing-relatedproblemsANS: COutcomes are projections of expected influence that nursing interventions will haveon the patient. Interviewing and collecting data is involved in the assessment process,re-assessing is involved in the evaluation process, and identifying related nursingproblems is involved in determining appropriate nursing diagnoses.DIF: Cognitive Level: Application REF: Page 49

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TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective CareEnvironment5. While discussing assessment of suicidal patients, a novice nurse mentions,“Iwastaught to always base my care on concrete, evidence-based scientific reasoning andnever to rely onintuition.”Which response by the experienced nurse showsunderstanding of intuitive reasoning?a.“That’swise,becauseintuitionwentoutoffavorwiththescientificrevolution.”b.“Criticalthinkingandintuitionareatoppositepoles.Keeprelyingonyourexpertise.”c.“It’spossiblethatintuitionaboutsuicidalityisgeneratedbytransferoffeelingsfromthepanurse.”d.“It’sbeendeterminedthatintuitionisnothingmorethatextrasensoryperception,sosomefsomedon’t.”ANS: CA“stronghunch”or a“gutfeeling”is an example of intuitive reasoning that isbelieved to come from the therapeuticrelationship’ssharing of feelings between nurseand patient. Most nurses agree that intuition is compatible with scientific reasoning,because both are likely linked to practice and experience. A nurse learns intuitivereasoning through clinical practice rather than from school or books.DIF: Cognitive Level: Application REF: Page 45TOP: Nursing Process: Analysis (Caring)MSC: NCLEX: Safe and Effective Care Environment6. A nurse shows effective critical thinking skills directed towards nursing care of acognitively impaired patient who continues to socially isolate by:a.Clearlystatingthatthepatientmustsociallyinteractoncedailyb.Documentingthatthepatientcontinuestoresistsocializationc.Askingthepatienttoidentifywhichunitactivitytheyarewillingtoattendd.SuggestingthatstafftakethepatientwiththemwhenrunningerrandsofftheunitANS: DCritical thinking in this case involves the creation of alternative solutions to a problemthat was not resolved by conventional methods. The remaining options, although notinappropriate, do not show critical thinking skillsDIF: Cognitive Level: Application REF: Page 45 TOP: Nursing Process: PlanningMSC: NCLEX: Safe and Effective Care Environment

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7. A depressed patient shares with the nurse that he,“hasbeen thinking about endingitall”.Based on NANDA recommendations, the nurse:a.Implementssuicideprecautionsforthispatientb.Includes‘RiskforSelfHarm’tothepatient’scareplanc.Documentsregardingthepatient’ssafetyevery15minutesd.Reviewsthepatient’schartforreferencestopastincidencesofhopelessANS: BNANDA states that a nurse is able to change any actual diagnosis on the NANDA listto 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 TOP: Nursing Process: AnalysisMSC: NCLEX: Safe and Effective Care Environment8. The nurse shows an understanding of the appropriate use of nursing outcomesregarding triggers for a patient diagnosed with chronic alcohol abuse when stating:a.“Canyouworkonidentifyingthreesituationsthatcauseyoutoabusealcohol?”b.”I’llhelpyoutoidentifythreetriggersforyourdrinkingduringtoday’ssession.”c.”I’mpleasedyou’veidentifiedthreesituationsthattriggeryourabuseofalcohol.”d.“Doyouthinkyouwillbeabletoavoidthethreetriggersthatcauseyoutodrink?”ANS: COutcomes sometimes referred to as behavioral goals are used to describe and evaluatethe effectiveness of nursing interventions. The correct option shows that the patientwas successful at accomplishing an outcome inferring the nursing interventions weresuccessful. The remaining options do not indicate an evaluation of success or failure.DIF: Cognitive Level: Application REF: Page 49 TOP: Nursing Process: EvaluationMSC: NCLEX: Psychosocial Integrity: Chemical and Other Dependencies9. When a patient experiencing acute depression asks what the difference is between amedical and a nursing diagnosis, the nurse responds best when stating:a.Actuallytheyareverysimilarinthattheybothareconcernedwithhelpingyougetbetteralife.b.Medicaldiagnosesarefocusedonwhyyouaredepressedwhereasnursingdiagnosesarecomakingyourlifelesssad.c.Nursingdiagnosesaremoredirectedatcaringforyou,unlikemedicaldiagnosesthatfocuscauseforyourproblem.

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d.Themedicaldiagnosisidentifiesthatyouareexperiencingdepressionwhereasthenursingidentifieshowthedepressionisaffectingyou.ANS: DThe medical diagnosis involves identifying a mental or physical problem that resultsin the symptoms that negatively affect apatient’slife. Although the nurse isknowledgeable about the disorders and their treatments, the nursing diagnosis focusesmainly on thepatient’sresponses to the disorder and the effects that the disorder hason the patient. The types of diagnoses have different foci that result in differentactions and concerns.DIF: Cognitive Level: Application REF: Page 49TOP: Nursing Process: Implementation (Teaching and Learning)MSC: NCLEX: Psychosocial Integrity: Therapeutic Communication10. A nurse best shows an understanding of the role of evidence-based research inachieving therapeutic patient care outcomes when:a.Subscribingtoandreadingamonthlypsychiatricresearchnursingjournalb.Workingonacommitteetorevisecurrentfacilitypoliciesregardingtheuseofchemicalrec.Registeringtoattendapsychiatricworkshoponnewlydevelopedpsychotropicmedicationd.AskinganexperiencedstaffmembertoreviewtheinterventionsbeingproposedforanewlpatientANS: BEvidence-based practice is based on evidence and scientific principles that have beendeveloped through research. The more closely clinical practice reflects relevantresearch, the more likely it is that patients will receive the best available care. Theoption that infers action directed at implementing the research is the one that showsbest understanding. Reliance only on experience is not reflective of quality nursingcare.DIF: Cognitive Level: Application REF: Page 51 TOP: Nursing Process: PlanningMSC: NCLEX: Safe and Effective Care Environment11. When caring for a patient admitted with a diagnosis if bipolar disorder, managedcare regulations is the driving force behind thenurse’suse of:a.NANDAnursingdiagnosesb.Short-termstressmanagementtherapyc.Aspecializedclinicalpathwayforsuchpatients

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d.GenericinsteadofbrandnamemedicationsANS: CManaged care regulations have brought about the use of clinical pathways (alsocalledcritical pathwaysor acare maps) which are standardized multidisciplinaryplanning tools thatmonitor patient care through projected caregiver interventionsandexpected patient outcomes with a projected timeline of success. NANDA nursingdiagnoses are not related to regulations or payment concerns. The implementation ofshort-term stress management therapy in an acute care psychiatric environment wouldnot be driven by managed care regulation or payment concerns. The use of genericmedications when appropriate is primarily cost driven.DIF: Cognitive Level: Application REF: Page 51TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective CareEnvironment12. A benefit of the implementation of clinical pathways is evidenced when thepatient states:a.“Iknowmydoctorsandnursesreallycareaboutme.”b.“Mymedicationhasreallyhelpedlessenmysymptoms.”c.“IhavehopesthatIwillbeabletoleadaproductive,healthylife.”d.“Mycareteamhasreallyhelpedmemanagemostofmyproblems.”ANS: DClinical pathways are tools that among other things promote interdisciplinary carethus providing for holistic care of the patient. The remaining options do not involvethe additional recognized benefits of clinical pathways that include cost effectivenessand access to patient status reports.DIF: Cognitive Level: Application REF: Page 54 TOP: Nursing Process: EvaluationMSC: NCLEX: Safe and Effective Care Environment13. A nurse shows the best understanding of the legal importance of thepatient’schartwhen stating:a.“Youalwaysdocumentininkandnevereraseoruse“whiteout”inthenursingnotes.”b.“It’sadocumentthatshowsproofthatthepatientreceivedcarethatmettheexpectedstandc.“Patientchartsarecarefullyprotectedfromunlawfulaccessbyinappropriateindividualsod.“Thepatienthasalegalrighttotheinformationcontainedinthechartbutnottheoriginalditself.”

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ANS: BThepatient’schart is a legal document that effectively communicates patientoutcomes, medications, treatments, responses, and unusual incidents reflecting thehealthcare 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 56TOP: Nursing Process: Implementation; (Teaching and Learning)MSC: NCLEX: Safe and Effective Care Environment14. The nurse best fulfills the obligation to be accountable for providing care thatmeets the expected standards of care when:a.Developingatherapeuticrelationswiththepatientb.Applyingevidence-basednursingpracticetotheplanofcarec.Providingappropriatedischargeplanningtomeetthepatient’sneedsd.EvaluatingtheeffectivenessofinterventionsthroughachievementofoutcomesANS: DEvaluation of thepatient’sprogress and the nursing activities involved are criticalbecause nurses are accountable for the standards of care in each discipline. Althoughthe other options reflect appropriate and expected nursing interventions, they are notthe primary means of assuring that standard of care has been met.DIF: Cognitive Level: Application REF: Page 56 TOP: Nursing Process: PlanningMSC: NCLEX: Safe and Effective Care Environment15. The nurse assesses apatient’sjudgment by asking:a.“Whydidyourunaway?”b.“Whendidyoufirststarthearingvoices?”c.“Whatwouldyoudoifyousmelledsmokeinyourhome?”d.“Doyoubelieveyouhearvoices,ordoyouthinkitisinyourmind?”ANS: CJudgment is the ability to assess and evaluate situations, make rational decisions,understand consequences of behavior, and take responsibility for actions. Judgmentmay be assessed by asking a question that has a common-sense answer. The otheroptions ask about motivation, elicits historical information about the illness or seeksinformation about insight.

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DIF: Cognitive Level: Application REF: Page 43TOP: Nursing Process: ImplementationMSC: NCLEX: Safe and Effective Care Environment; Psychological Integrity16. The nurse responsible for the care plan of a patient diagnosed with cognitiveimpairment includes rationales for the nursing interventions primarily to:a.Provideameansforoutcomeevaluationb.Accountforthereasoningthatdrivesthenursingactionc.Supportthepatient’ssuccessinachievingtheexpectedoutcomed.ProvideinformationtoaideintheimplementationofthenursingactionANS: BRationales primarily reflectnurses’accountability for their actions by explaining whythe action is necessary and expected to positively impact thepatient’scondition.Rationales are not used to support or evaluate the success of the intervention nor toeducate how the action should be preformed.DIF: Cognitive Level: Application REF: Page 56 TOP: Nursing Process: PlanningMSC: NCLEX: Safe and Effective Care Environment17. A patient who has a nursing diagnosis of ineffective coping related to ineffectiveproblem solving has been involved in treatment for 6 months. The nurse determinesthat the planned interventions require revision when the patient states:a.“Ireallydon’tthinkmypsychiatristactuallyhelpsme.”b.“Ican’tdecideifIshouldgetmyownapartmentornot.”c.“Ican’tacceptthatIwillneverbeabletocomfortablymakedecisions.”d.“Idon’tthinkI’mlikedwellenoughtoseekelectionasacommitteechairperson.”ANS: BNursing interventions describe a specific course of action or a therapeutic activity thathelps the patient to move toward a more functional state; in this case problem solving.The statement indicates indecision and suggests that problem solving is still a patientproblem. Showing dislike of the physician actually shows a decision. Notacceptingthe realization of ineffective decision making is not related to ineffective coping butrather shows focus on affecting the problem. Expressing the perception that one is notliked concerns self-esteem.DIF: Cognitive Level: Application REF: Page 54 TOP: Nursing Process: Evaluation

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MSC: NCLEX: Safe and Effective Care Environment; Psychological Integrity18. To best facilitate interdisciplinary communication regarding the plan of care for apatient diagnosed with paranoid schizophrenia, the nurse:a.Requiresweeklymeetingsofthecareteamb.Ensurestheteamincludesmembersfromallappropriatedisciplinesc.UsesthestandardizedNICclassificationsystemofcareinterventionsd.RecognizestheneedforteamaccesstopatientrecordsandmakesthemavailableANS: CThe Nursing Interventions Classification (NIC)is the first comprehensivestandardized classification of interventions. The NIC states that one should not changeintervention labels and definitions so that there is no confusion across settings.Although not inappropriate, the remaining options do not directly minimize confusionrelated to communication.DIF: Cognitive Level: Application REF: Page 55TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective CareEnvironment19. When reviewing the history of a newly admitted patient diagnosed with severechronic depression, the nurse is most concerned about patient safety issues whennoting:a.Thepatient’sAxisIIincludesadiagnosisofmentalretardationb.Documentationthatthepatienthasbeennoncompliantregardingmedicationsc.Thepatient’scurrentGlobalAssessmentofFunctioning(GAF)Scaleratingis9d.Referencetoarecentphysicalinjuryresultingfromthepatient’simpulsivebehaviorANS: CThe Global Assessment of Functioning (GAF) Scale is one of the tools use to assesspatient functioning and possible prognosis. It is coded on a numerical continuum, with1 indicating little danger and 10 indicating severe or persistent danger, and possiblesuicidal potential. Mental deficiency may contribute to issues of safety but it is not asignificant risk factor. Noncompliance may contribute to thepatient’sdepression butit is not the greatest concern identified. Although past history is considered a predictorof future behavior, this is more related to the safety of others than to the patient.DIF: Cognitive Level: Application REF: Page 49

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TOP: Nursing Process: AssessmentMSC: NCLEX: Safe and Effective Care Environment; Psychological Integrity20. An appropriate nursing diagnosis for a patient who manifests a psychologicalproblem through frequent expressions of unfounded or excessive guilt or shame, statesthat he is unable to deal with situations, and has a hesitation to try new things wouldbe:a.Hopelessnessb.Powerlessnessc.Ineffectivecopingd.Chroniclowself-esteemANS: DThe behaviors mentioned in the situation are congruent with criteria for the diagnosisof chronic low self-esteem. Thepatient’ssymptoms go beyond powerlessness.Hopelessness does not involve feelings of guilt and shame. The data is not consistentwith a diagnosis of ineffective coping.DIF: Cognitive Level: Application REF: Page 47 TOP: Nursing Process: AnalysisMSC: NCLEX: Safe and Effective Care Environment; Psychological Integrity21. A well-stated outcome criteria for a patient with a nursing diagnosis of risk forloneliness related to social isolation would include“Thepatient will:a.Nolongerexperiencelonelinessbytheendofthefifthdayofhospitalization.”b.Agreetoattendtwoon-unit,staff-directedgroupsessionsdaily.”c.Continuetomaintainsocialsolitude50%ofthetime.”d.Interactwithapeeronadailybasisbydischarge.”ANS: DOutcome criteria for a risk diagnosis are developed from the risk factors—in this case,social isolation. Outcomes meet criteria when they are measurable, specific, andpresent a timeline for completion. The correct option meets all criteria. There is nostated means by which to measure loneliness. Agreeing to attend is not specificallydirected at affecting social isolation since interaction is not an expectation. Socialsolitude promotes social isolation.DIF: Cognitive Level: Application REF: Page 49 TOP: Nursing Process: PlanningMSC: NCLEX: Safe and Effective Care Environment; Psychological Integrity

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22. Care planning for a patient diagnosed with paranoid schizophrenia will include:a.Analyzingeffectivenessofcareprovidedb.Determiningthepatient’sneedsandproblemsc.Establishingrealisticpatient-focusedoutcomecriteriad.Identifyingprioritiesofcarebasedonthepatient’sconditionANS: DEstablishing priority nursing diagnoses is part of the process of planning. Determiningneeds is part of assessment. Analyzing effectiveness is an evaluation activity.Establishing realistic expectations is part of outcome identification.DIF: Cognitive Level: Application REF: Page 51 TOP: Nursing Process: PlanningMSC: NCLEX: Safe and Effective Care Environment23. The expert nurse is confident that the novice nurse understands the principles thatguide the planning of patient care interventions when the:a.Novicenurseasksthepatienttoidentifytheirprimaryconcernsb.Patientsuccessfullyachievestheagreeduponnursingoutcomesc.Expertnurserequeststhatthenovicenurseobserveseveralcareplanningsessionsd.Novicenurseincludesinterventionsthataresupportedbyevidence-basedpracticesANS: AWorking with the patient to determine treatment priorities is a characteristic of goodcare planning. Although successful achievement of expected outcomes and inclusionof EBP interventions reflect appropriate care planning, such success is influenced bymany different factors. Although appropriate, observing care planning sessions doesnot necessarily affect successful care planning on the part of the novice nurse.DIF: Cognitive Level: Application REF: Page 51 TOP: Nursing Process: AnalysisMSC: NCLEX: Safe and Effective Care EnvironmentChapter 04: Therapeutic CommunicationFortinash: Psychiatric Mental Health Nursing, 5th EditionChapter 04: Therapeutic CommunicationTest BankMULTIPLE CHOICE1. An example of an environmental factor that would cause a nurse to modify aplanned critical interaction occurs when the:

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a.Patientexpressesapersonaldislikeforthenurseb.Patientisintotaldenialaboutherconditionc.Nurselacksthedegreeofknowledgerequiredfortheinteractiond.Nurselearnsthatthepatient’smotherhasbeenhospitalizedwithastrokeANS: DEnvironmental factors include timing. Timing of critical interventions is important. Itshould occur when the individual can give full attention to the topic. It would beinappropriate to continue with the plan in the face of thepatient’sdistress related tohermother’sillness. The remaining options reflect other types of factors thatinfluence communication such as attitudes, knowledge, and relationships.DIF: Cognitive Level: Application REF: Page 63TOP: Nursing Process: Planning (Communication and Documentation)MSC: NCLEX: Psychosocial Integrity2. The nurse suspects that thepatient’scommunication is being negatively influencedby personal attitude when he is heard stating:a.“TheythinkI’mmentallyillbutI’mnot;Ijustgetalittledepressedattimes.”b.“Ican’tconcentrateonanythingbesidesgettingoutofhereandbacktomykids.”c.“Obviouslymytherapistcan’tunderstandwhereI’mcomingfrombecauseourlivesaresod.“Thereisn’tanyonehereinthishospitalIcantrustenoughtotalktoaboutwhyIabusealcANS: CAttitude determines how one person responds to another. It includesone’sbiases, pastexperiences, and openness. People of different socioeconomic backgrounds may havedifficulty surmounting this barrier. The remaining options reflect factors that cannegatively influence communication but they are environmental, knowledge, andrelationship oriented.DIF: Cognitive Level: Application REF: Page 64TOP: Nursing Process: Assessment (Communication and Documentation)MSC: NCLEX: Psychosocial Integrity3. The nature of the communication characterized in this exchange between a nurseand a chronically depressed patient is:Nurse: Is it true that you enjoy knitting?Patient: Yes,I’vedone it for years and am pretty good at it.

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Nurse:I’mjust a beginner. Do you think you could give me some tips?Patient: I guess so. What would you like to know?a.Therapeuticb.Collegialc.Sociald.IntrapersonalANS: CAlthough the conversation takes place between the nurse and a patient, it is of a socialnature. It is superficial and benefits both parties mutually by encouraging arelationship based on mutual interest. No expectation of help exists. Therapeuticcommunication promotes patient growth and is patient-focused. Collegialconversation occurs for the purpose of professional collaboration. Intrapersonalcommunication takes place within the individual.DIF: Cognitive Level: Comprehension REF: Page 66TOP: Nursing Process: Implementation (Communication and Documentation)MSC: NCLEX: Psychosocial Integrity4. A patient expresses a sense of genuineness in the nurse providing care whensharing with family members that:a.“IbelievethenursecanfeelwhatI’mfeeling.”b.“Ialwaysknowwhatthenurseexpectsofme;theexplanationsarealwaysclear.”c.“Icantellthenurseissincerebecausethefacesupportswhatthemouthissaying.”d.“ImaynotalwayslikewhatthenursehastosaybutIcanalwaysdependonwhatI’mtoldANS: CGenuineness is demonstrated by congruence between verbal and nonverbal behavior.Empathy is seeing things from thepatient’sviewpoint. Clearly stating expectations isa characteristic of clarity. Trustworthiness can be described as dependability.DIF: Cognitive Level: Application REF: Page 69TOP: Nursing Process: Implementation (Communication and Documentation)MSC: NCLEX: Psychosocial Integrity5. When providing discharge teaching to a patient for whom English is a secondlanguage, what technique will the nurse use to assess thepatient’sunderstanding ofthe information being shared verbally?

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a.Continuouslyevaluatingthepatient’snonverbalcuesb.Periodicallyaskingthepatientiftheyhaveanyquestionsc.Askingthepatienttorepeattheinformationtheyaregivend.Providingtheinformationinconcise,writtenformANS: AIndividuals from different cultures or even different generations often misunderstandand misinterpret an unfamiliar language.Being aware of and critically examining cuesthat result fromnonverbal responses is an excellent technique to check theirinterpretations. Asking if they have questions is an ineffective technique in light of thelanguage barrier. Repeating the information is no guarantee that the patientunderstands the information. Providing the information in written form reinforces thematerial but does not ensure understanding especially if the patient has deficienciesrelated to reading the language.DIF: Cognitive Level: Application REF: Page 64TOP: Nursing Process: Planning (Communication and Documentation)MSC: NCLEX: Psychosocial Integrity6. When communicating with a psychotic, schizophrenic patient, the nurse avoids theuse of slang phrases most importantly because:a.Suchphraseshavedifferentmeaningsfordifferentpeople.b.Suchphraseswilllikelytriggeranxietyandfrustrationinthepatient.c.Theuseofsuchphrasesisnotappropriatewhencommunicatingtherapeuticallywithapatid.Thispatient’salteredthoughtprocesseswillservetomakeunderstandingsuchphrasesverANS: DPrecise verbal communication is important because spoken words often meandifferent things to different people. Figures of speech, jokes, clichés, colloquialisms,and other terms or special phrases carry a variety of meanings especially toindividuals with altered thought processes. A person with schizophrenia interpretsconcretely and literally whereas psychosis generally brings about loose associations.Although all the options are reasons to avoid the use of slang phrases, the primaryreason in this case in to avoid confusing the patient.DIF: Cognitive Level: Analysis REF: Page 64TOP: Nursing Process: Planning (Communication and Documentation)

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MSC: NCLEX: Psychosocial Integrity7. The nurse is considering the need for both effective means of communication andsafety when caring for a patient with impulse control issues and poor social skills.Which nursing intervention is most appropriate to address these needs?a.Remindingthepatientwitheachinteractionwhatspaceboundariesareconsideredsafeandb.Askingthepatienttodescribeandsetspaceboundariesthatfeelsafeandfacilitateeffectivc.Clearlysettingspaceboundariesforthepatientsobothpatientandstafffeelsafeandcancmoreeffectivelyd.DiscussingtheneedforspaceboundariesandhowtheyhelpboththepatientandthestafffincommunicatingeffectivelyANS: DSpace as a concept of boundaries and safety is important to understand because thenurse and the patient need to respect the distance that each needs. For successfulcommunication to occur, both parties need to feel safe. Some patients have problemswith their boundaries and invade otherpatients’own safe zones; patients whoperceive this as threatening react aggressively to such boundary violations. The nursemay need to help the patient understand the need for appropriate distances in order foreveryone to feel safe and to communicate effectively. Reminding the patient of whatthe boundaries are without first discussing the importance of space boundaries is notan effective technique. Having the patient set the boundaries does not take intoconsideration the needs of others, whereas staff setting the boundaries without patientinvolvement ignores the needs of the patient and prevents the patient fromunderstanding of the situation.DIF: Cognitive Level: Application REF: Page 65TOP: Nursing Process: Planning (Communication and Documentation)MSC: NCLEX: Safe and Effective Care Environment; Psychosocial Integrity8. During the termination phase of the nurse-patient relationship with a dependentpatient, the nurse evaluates the effectiveness of coping techniques learned by:a.Roleplayingwiththepatientinordertopracticebeingassertiveb.Askingthepatienttodefinethedifferencebetweenbeingassertiveandbeingaggressive.c.Discussinghowherfathereffectivelyusedbothassertivenessandaggressivenesstocontrod.Asking,“Whenyouusedassertivenesstodealwithyourfatherduringhisvisit,howdiditANS: D

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