Mental Health Nursing 6th edition Fontaine Test Bank

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  • Download: Mental Health Nursing 6th edition Fontaine Test Bank
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  • Published: 2008
  • ISBN-10: 0135146550
  • ISBN-13: 978-0135146552

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mental health nursing 6th edition fontaine test bank

Fontaine: Mental Health Nursing, 6e

Chapter 1: Introduction to Mental Health Nursing

 MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the question.

1) The nurse is teaching the family various factors that are important in understanding the concepts of mental

health and mental illness. What factors should be included in the nurse’s teaching?

Select all that apply.

A) Interpersonal factors

B) Personal factors

C) Culture

D) Brain function

E) Social conditions

Answer: A, B, C, D, E

Explanation: A) Movement toward the mental illness end of the continuum may begin with a sense of

disharmony that is distressing to family or friends.

Cognitive Level: Application

Nursing Process: Planning

Client Need: Psychosocial Integrity

B) Movement toward the mental illness end of the continuum may begin with a sense of

disharmony that is distressing to the individual.

Cognitive Level: Application

Nursing Process: Planning

Client Need: Psychosocial Integrity

C) Behavior that can be considered as being at the mental illness end of the continuum in one

culture can be considered normal and acceptable in another culture.

Cognitive Level: Application

Nursing Process: Planning

Client Need: Psychosocial Integrity

D) Research has shown that brain chemicals and processes are frequently altered in mental

illnesses.

Cognitive Level: Application

Nursing Process: Planning

Client Need: Psychosocial Integrity

E) Movement toward the mental illness end of the continuum may begin with a sense of

disharmony that is distressing to the community or society.

Cognitive Level: Application

Nursing Process: Planning

Client Need: Psychosocial Integrity

2) During the nursing assessment of an adult client, the nurse finds the client’s beliefs and actions related to

common health practices to be “bizarre.” Which action would be most appropriate for the nurse to take at this

time?

A) Write a nursing diagnosis to address the “bizarre” beliefs and actions.

B) Repeat the assessment later in the day.

C) Inquire as to the culture with which the client identifies.

D) Communicate the findings to the health care team.

Answer: C

1

Explanation: A) A thorough assessment is needed before proceeding with other steps of the nursing process.

Cultural beliefs strongly influence what is defined as mental illness or mental health. Behavior

that is considered bizarre in one cultural context may be considered desirable in another. While

findings will be communicated and used for nursing diagnosis formulation later in the process,

these steps are built upon a thorough assessment. Repeating the assessment without the

cultural assessment will most likely result in the same incomplete data.

Cognitive Level: Application

Nursing Process: Implementation

Client Need: Psychosocial Integrity

B) A thorough assessment is needed before proceeding with other steps of the nursing process.

Cultural beliefs strongly influence what is defined as mental illness or mental health. Behavior

that is considered bizarre in one cultural context may be considered desirable in another. While

findings will be communicated and used for nursing diagnosis formulation later in the process,

these steps are built upon a thorough assessment. Repeating the assessment without the

cultural assessment will most likely result in the same incomplete data.

Cognitive Level: Application

Nursing Process: Implementation

Client Need: Psychosocial Integrity

C) A thorough assessment is needed before proceeding with other steps of the nursing process.

Cultural beliefs strongly influence what is defined as mental illness or mental health. Behavior

that is considered bizarre in one cultural context may be considered desirable in another. While

findings will be communicated and used for nursing diagnosis formulation later in the process,

these steps are built upon a thorough assessment. Repeating the assessment without the

cultural assessment will most likely result in the same incomplete data.

Cognitive Level: Application

Nursing Process: Implementation

Client Need: Psychosocial Integrity

D) A thorough assessment is needed before proceeding with other steps of the nursing process.

Cultural beliefs strongly influence what is defined as mental illness or mental health. Behavior

that is considered bizarre in one cultural context may be considered desirable in another. While

findings will be communicated and used for nursing diagnosis formulation later in the process,

these steps are built upon a thorough assessment. Repeating the assessment without the

cultural assessment will most likely result in the same incomplete data.

Cognitive Level: Application

Nursing Process: Implementation

Client Need: Psychosocial Integrity

3) The nurse is sharing client assessment data with the mental health care team. Which comment by the nurse is

most likely irrelevant and indicates a misunderstanding of mental illness? “The client reports:

A) Significant emotional distress about the current situation.”

B) A lot of time is spent in fear and anxiety.”

C) A loss of interest in usual pleasurable interpersonal relationships.”

D) Some very different religious ideas and spiritual beliefs.”

Answer: D

Explanation: A) Religious ideas and spiritual beliefs are culturally grounded and are not generally labeled as

symptoms of mental illness, unless the deviance is causing a sense of disharmony to the

individual, family, friends, community, or society. Therefore, this choice indicates a

misunderstanding of the concept of mental illness. Reports of fear, anxiety, emotional distress,

and disharmony with interpersonal relationships are very relevant and are indications of the

client’s movement toward the mental illness end of the continuum.

Cognitive Level: Application

Nursing Process: Evaluation

Client Need: Psychosocial Integrity

2

B) Religious ideas and spiritual beliefs are culturally grounded and are not generally labeled as

symptoms of mental illness, unless the deviance is causing a sense of disharmony to the

individual, family, friends, community, or society. Therefore, this choice indicates a

misunderstanding of the concept of mental illness. Reports of fear, anxiety, emotional distress,

and disharmony with interpersonal relationships are very relevant and are indications of the

client’s movement toward the mental illness end of the continuum.

Cognitive Level: Application

Nursing Process: Evaluation

Client Need: Psychosocial Integrity

C) Religious ideas and spiritual beliefs are culturally grounded and are not generally labeled as

symptoms of mental illness, unless the deviance is causing a sense of disharmony to the

individual, family, friends, community, or society. Therefore, this choice indicates a

misunderstanding of the concept of mental illness. Reports of fear, anxiety, emotional distress,

and disharmony with interpersonal relationships are very relevant and are indications of the

client’s movement toward the mental illness end of the continuum.

Cognitive Level: Application

Nursing Process: Evaluation

Client Need: Psychosocial Integrity

D) Religious ideas and spiritual beliefs are culturally grounded and are not generally labeled as

symptoms of mental illness, unless the deviance is causing a sense of disharmony to the

individual, family, friends, community, or society. Therefore, this choice indicates a

misunderstanding of the concept of mental illness. Reports of fear, anxiety, emotional distress,

and disharmony with interpersonal relationships are very relevant and are indications of the

client’s movement toward the mental illness end of the continuum.

Cognitive Level: Application

Nursing Process: Evaluation

Client Need: Psychosocial Integrity

3

4) The psychiatric-mental health nurse is collecting data regarding the client’s position on the mental

health-mental illness continuum. Which client behavior will be most relevant to the assessment of insight? The

client is:

A) Laughing at a few humorous aspects of the current situation.

B) Identifying goals and making plans for the future.

C) Demonstrating the ability to accomplish simple problem-solving.

D) Self-evaluating personal values, attitudes, and behaviors.

Answer: D

Explanation: A) The ability to self-evaluate or ask difficult interpersonal questions and give honest answers

indicates the degree of insight. While finding humor in situations, problem-solving, identifying

goals and making plans are indications of the mental health factor of resilience; these do not

directly measure insight.

Cognitive Level: Application

Nursing Process: Assessment

Client Need: Psychosocial Integrity

B) The ability to self-evaluate or ask difficult interpersonal questions and give honest answers

indicates the degree of insight. While finding humor in situations, problem-solving, identifying

goals and making plans are indications of the mental health factor of resilience; these do not

directly measure insight.

Cognitive Level: Application

Nursing Process: Assessment

Client Need: Psychosocial Integrity

C) The ability to self-evaluate or ask difficult interpersonal questions and give honest answers

indicates the degree of insight. While finding humor in situations, problem-solving, identifying

goals and making plans are indications of the mental health factor of resilience; these do not

directly measure insight.

Cognitive Level: Application

Nursing Process: Assessment

Client Need: Psychosocial Integrity

D) The ability to self-evaluate or ask difficult interpersonal questions and give honest answers

indicates the degree of insight. While finding humor in situations, problem-solving, identifying

goals and making plans are indications of the mental health factor of resilience; these do not

directly measure insight.

Cognitive Level: Application

Nursing Process: Assessment

Client Need: Psychosocial Integrity

5) The client’s spouse is verbalizing feelings of guilt and asks the cause of the client’s mental illness. What is the

nurse’s correct response?

A) “Mental illness is the result of a brain disorder.”

B) “No one really knows the cause of mental illness.”

C) “Why do you think the mental illness occurred?”

D) “Sometimes people just let their problems make themselves sick.”

Answer: A

4

Explanation: A) Genetic and neurobiological data indicate that mental illness is basically a brain disorder. All

functions of the mind reflect functions in the brain. Research has provided many theories as to

the cause of mental illness. Even though cultural, intrapersonal, and interpersonal factors

impact movement on the mental illness-mental health continuum, the overall causative factors

are neurobiological and not the “fault” of the individual. This “at-fault” belief contributes to the

stigma associated with mental illness. Asking the spouse their perception as to why the mental

illness occurred does not take the opportunity to teach, puts the spouse in a perceived defensive

position, does not answer the spouse’s question, and contributes to the inaccurate perception

that mental illness might be under personal control.

Cognitive Level: Application

Nursing Process: Implementation

Client Need: Psychosocial Integrity

B) Genetic and neurobiological data indicate that mental illness is basically a brain disorder. All

functions of the mind reflect functions in the brain. Research has provided many theories as to

the cause of mental illness. Even though cultural, intrapersonal, and interpersonal factors

impact movement on the mental illness-mental health continuum, the overall causative factors

are neurobiological and not the “fault” of the individual. This “at-fault” belief contributes to the

stigma associated with mental illness. Asking the spouse their perception as to why the mental

illness occurred does not take the opportunity to teach, puts the spouse in a perceived defensive

position, does not answer the spouse’s question, and contributes to the inaccurate perception

that mental illness might be under personal control.

Cognitive Level: Application

Nursing Process: Implementation

Client Need: Psychosocial Integrity

C) Genetic and neurobiological data indicate that mental illness is basically a brain disorder. All

functions of the mind reflect functions in the brain. Research has provided many theories as to

the cause of mental illness. Even though cultural, intrapersonal, and interpersonal factors

impact movement on the mental illness-mental health continuum, the overall causative factors

are neurobiological and not the “fault” of the individual. This “at-fault” belief contributes to the

stigma associated with mental illness. Asking the spouse their perception as to why the mental

illness occurred does not take the opportunity to teach, puts the spouse in a perceived defensive

position, does not answer the spouse’s question, and contributes to the inaccurate perception

that mental illness might be under personal control.

Cognitive Level: Application

Nursing Process: Implementation

Client Need: Psychosocial Integrity

D) Genetic and neurobiological data indicate that mental illness is basically a brain disorder. All

functions of the mind reflect functions in the brain. Research has provided many theories as to

the cause of mental illness. Even though cultural, intrapersonal, and interpersonal factors

impact movement on the mental illness-mental health continuum, the overall causative factors

are neurobiological and not the “fault” of the individual. This “at-fault” belief contributes to the

stigma associated with mental illness. Asking the spouse their perception as to why the mental

illness occurred does not take the opportunity to teach, puts the spouse in a perceived defensive

position, does not answer the spouse’s question, and contributes to the inaccurate perception

that mental illness might be under personal control.

Cognitive Level: Application

Nursing Process: Implementation

Client Need: Psychosocial Integrity

5

6) The psychiatric-mental health nurse is employed in a community mental health center that uses a

neurobiological theoretical perspective to guide treatment. The nurse understands that the neurobiological

principle that supports the use of counseling and therapy is that these treatment modalities:

A) Increase the client’s capacity for self-discovery of unconscious personality components.

B) Allow for reinforcement of desirable thoughts, feelings, and behaviors.

C) Create changes through learning that in turn create changes in neuronal functioning.

D) Encourage completion of developmental tasks that were not successfully completed earlier in life.

Answer: C

Explanation: A) Neurobiological theory offers the belief that all functions of the mind reflect functions of the

brain and includes the principle that counseling and therapy can create long-term changes

through learning which in turn creates changes in neuronal functioning. Self-discovery of

unconscious personality components, completion of developmental tasks, and reinforcement of

desirable thoughts, feelings, and behaviors describe earlier prebiological models of mental

disorders rather than principles associated with neurobiological theory.

Cognitive Level: Analysis

Nursing Process: Planning

Client Need: Psychosocial Integrity

B) Neurobiological theory offers the belief that all functions of the mind reflect functions of the

brain and includes the principle that counseling and therapy can create long-term changes

through learning which in turn creates changes in neuronal functioning. Self-discovery of

unconscious personality components, completion of developmental tasks, and reinforcement of

desirable thoughts, feelings, and behaviors describe earlier prebiological models of mental

disorders rather than principles associated with neurobiological theory.

Cognitive Level: Analysis

Nursing Process: Planning

Client Need: Psychosocial Integrity

C) Neurobiological theory offers the belief that all functions of the mind reflect functions of the

brain and includes the principle that counseling and therapy can create long-term changes

through learning which in turn creates changes in neuronal functioning. Self-discovery of

unconscious personality components, completion of developmental tasks, and reinforcement of

desirable thoughts, feelings, and behaviors describe earlier prebiological models of mental

disorders rather than principles associated with neurobiological theory.

Cognitive Level: Analysis

Nursing Process: Planning

Client Need: Psychosocial Integrity

D) Neurobiological theory offers the belief that all functions of the mind reflect functions of the

brain and includes the principle that counseling and therapy can create long-term changes

through learning which in turn creates changes in neuronal functioning. Self-discovery of

unconscious personality components, completion of developmental tasks, and reinforcement of

desirable thoughts, feelings, and behaviors describe earlier prebiological models of mental

disorders rather than principles associated with neurobiological theory.

Cognitive Level: Analysis

Nursing Process: Planning

Client Need: Psychosocial Integrity

6

7) The psychiatric-mental health nurse is admitting a new client to the psychiatric unit. Given the contemporary

neurobiological perspective of mental disorders, the nurse’s priority assessment is:

A) A family history of mental illness.

B) The content and frequency of recent dreams.

C) The degree of satisfaction with interpersonal relationships.

D) A description of self-esteem.

Answer: A

Explanation: A) Neurobiological research theorizes a genetic susceptibility and a familial genetic anticipation;

therefore, a family history of mental illness becomes priority information in a nursing

assessment. While self-esteem, interpersonal relationships, and perhaps dreams will be

assessed at some point, these concepts are derived from earlier prebiological theories and are

not the priority in this situation.

Cognitive Level: Application

Nursing Process: Assessment

Client Need: Psychosocial Integrity

B) Neurobiological research theorizes a genetic susceptibility and a familial genetic anticipation;

therefore, a family history of mental illness becomes priority information in a nursing

assessment. While self-esteem, interpersonal relationships, and perhaps dreams will be

assessed at some point, these concepts are derived from earlier prebiological theories and are

not the priority in this situation.

Cognitive Level: Application

Nursing Process: Assessment

Client Need: Psychosocial Integrity

C) Neurobiological research theorizes a genetic susceptibility and a familial genetic anticipation;

therefore, a family history of mental illness becomes priority information in a nursing

assessment. While self-esteem, interpersonal relationships, and perhaps dreams will be

assessed at some point, these concepts are derived from earlier prebiological theories and are

not the priority in this situation.

Cognitive Level: Application

Nursing Process: Assessment

Client Need: Psychosocial Integrity

D) Neurobiological research theorizes a genetic susceptibility and a familial genetic anticipation;

therefore, a family history of mental illness becomes priority information in a nursing

assessment. While self-esteem, interpersonal relationships, and perhaps dreams will be

assessed at some point, these concepts are derived from earlier prebiological theories and are

not the priority in this situation.

Cognitive Level: Application

Nursing Process: Assessment

Client Need: Psychosocial Integrity

8) The psychiatric-mental health nurse is planning interventions for a client using the diathesis-stress model as a

theoretical guide. Given this framework, which of the following nursing interventions should be included in the

plan of care?

A) Teach anxiety management skills for use in various situations.

B) Assist to identify ways to achieve self-actualization.

C) Assist to identify strategies to delay gratification.

D) Teach common defense mechanisms.

Answer: A

7

Explanation: A) The diathesis-stress model proposes that disease develops in biologically vulnerable persons

when exposed to stressors; therefore, anxiety management skills to decrease the impact of the

stressors are appropriate and should be included as interventions. Defense mechanisms and

gratification issues (Freud), and self-actualization (Maslow) are associated with older

intrapersonal and social-interpersonal theories.

Cognitive Level: Application

Nursing Process: Planning

Client Need: Psychosocial Integrity

B) The diathesis-stress model proposes that disease develops in biologically vulnerable persons

when exposed to stressors; therefore, anxiety management skills to decrease the impact of the

stressors are appropriate and should be included as interventions. Defense mechanisms and

gratification issues (Freud), and self-actualization (Maslow) are associated with older

intrapersonal and social-interpersonal theories.

Cognitive Level: Application

Nursing Process: Planning

Client Need: Psychosocial Integrity

C) The diathesis-stress model proposes that disease develops in biologically vulnerable persons

when exposed to stressors; therefore, anxiety management skills to decrease the impact of the

stressors are appropriate and should be included as interventions. Defense mechanisms and

gratification issues (Freud), and self-actualization (Maslow) are associated with older

intrapersonal and social-interpersonal theories.

Cognitive Level: Application

Nursing Process: Planning

Client Need: Psychosocial Integrity

D) The diathesis-stress model proposes that disease develops in biologically vulnerable persons

when exposed to stressors; therefore, anxiety management skills to decrease the impact of the

stressors are appropriate and should be included as interventions. Defense mechanisms and

gratification issues (Freud), and self-actualization (Maslow) are associated with older

intrapersonal and social-interpersonal theories.

Cognitive Level: Application

Nursing Process: Planning

Client Need: Psychosocial Integrity

9) The psychiatric-mental health nurse attends a presentation on various theories of mental disorders. Which

comment by the psychiatric nurse indicates an understanding of intrapersonal theories of personality

development?

A) “Personality is manifested only in a person’s interactions with another person or group.”

B) “Personality is more strongly shaped by events occurring in the earliest years of life than by those

occurring later.”

C) “Every human’s personality is genetically driven and individually developed.”

D) “People become who they are through a learning process using reinforcements and punishments.”

Answer: B

Explanation: A) Intrapersonal theorists believe that personality is shaped by events occurring in the earliest

years of life. This theory states that symptoms of mental disorders are rooted in events in the

first five years of life. The theory that personality is genetically driven and individually

developed is consistent with neurobiological theory. The theory that personality is manifested

only in a person’s interactions with others is more congruent with social-interpersonal theory,

particularly Harry Stack Sullivan. The theory that people become who they are through a

learning process using reinforcements and punishments reflects behavioral theory, particularly

B.F. Skinner.

Cognitive Level: Analysis

Nursing Process: Evaluation

Client Need: Psychosocial Integrity

8

B) Intrapersonal theorists believe that personality is shaped by events occurring in the earliest

years of life. This theory states that symptoms of mental disorders are rooted in events in the

first five years of life. The theory that personality is genetically driven and individually

developed is consistent with neurobiological theory. The theory that personality is manifested

only in a person’s interactions with others is more congruent with social-interpersonal theory,

particularly Harry Stack Sullivan. The theory that people become who they are through a

learning process using reinforcements and punishments reflects behavioral theory, particularly

B.F. Skinner.

Cognitive Level: Analysis

Nursing Process: Evaluation

Client Need: Psychosocial Integrity

C) Intrapersonal theorists believe that personality is shaped by events occurring in the earliest

years of life. This theory states that symptoms of mental disorders are rooted in events in the

first five years of life. The theory that personality is genetically driven and individually

developed is consistent with neurobiological theory. The theory that personality is manifested

only in a person’s interactions with others is more congruent with social-interpersonal theory,

particularly Harry Stack Sullivan. The theory that people become who they are through a

learning process using reinforcements and punishments reflects behavioral theory, particularly

B.F. Skinner.

Cognitive Level: Analysis

Nursing Process: Evaluation

Client Need: Psychosocial Integrity

D) Intrapersonal theorists believe that personality is shaped by events occurring in the earliest

years of life. This theory states that symptoms of mental disorders are rooted in events in the

first five years of life. The theory that personality is genetically driven and individually

developed is consistent with neurobiological theory. The theory that personality is manifested

only in a person’s interactions with others is more congruent with social-interpersonal theory,

particularly Harry Stack Sullivan. The theory that people become who they are through a

learning process using reinforcements and punishments reflects behavioral theory, particularly

B.F. Skinner.

Cognitive Level: Analysis

Nursing Process: Evaluation

Client Need: Psychosocial Integrity

10) The psychiatric-mental health nurse is planning care for the client. The nurse first plans to establish a

therapeutic nurse-client relationship. Which theorist espouses a therapeutic nurse-client relationship?

A) B.F. Skinner

B) Hildegard Peplau

C) Erik Erickson

D) Abraham Maslow

Answer: B

Explanation: A) Hildegard Peplau, the mother of psychiatric nursing, defined nursing as an interpersonal

process using the nurse-client relationship to facilitate change in the client. B.F. Skinner, a

behavioral theorist, promoted learning through the use of reinforcements and punishment as

an avenue for behavioral change. Erik Erickson, an intrapersonal theorist, saw personality and

change continuing throughout the life span. Erickson used his intrapersonal theory of

psychotherapy to help individuals return to childhood issues to finish incomplete

developmental tasks. Abraham Maslow, a social-interpersonal theorist, believed in a priority of

needs from a humanistic perspective.

Cognitive Level: Analysis

Nursing Process: Planning

Client Need: Psychosocial Integrity

9

B) Hildegard Peplau, the mother of psychiatric nursing, defined nursing as an interpersonal

process using the nurse-client relationship to facilitate change in the client. B.F. Skinner, a

behavioral theorist, promoted learning through the use of reinforcements and punishment as

an avenue for behavioral change. Erik Erickson, an intrapersonal theorist, saw personality and

change continuing throughout the life span. Erickson used his intrapersonal theory of

psychotherapy to help individuals return to childhood issues to finish incomplete

developmental tasks. Abraham Maslow, a social-interpersonal theorist, believed in a priority of

needs from a humanistic perspective.

Cognitive Level: Analysis

Nursing Process: Planning

Client Need: Psychosocial Integrity

C) Hildegard Peplau, the mother of psychiatric nursing, defined nursing as an interpersonal

process using the nurse-client relationship to facilitate change in the client. B.F. Skinner, a

behavioral theorist, promoted learning through the use of reinforcements and punishment as

an avenue for behavioral change. Erik Erickson, an intrapersonal theorist, saw personality and

change continuing throughout the life span. Erickson used his intrapersonal theory of

psychotherapy to help individuals return to childhood issues to finish incomplete

developmental tasks. Abraham Maslow, a social-interpersonal theorist, believed in a priority of

needs from a humanistic perspective.

Cognitive Level: Analysis

Nursing Process: Planning

Client Need: Psychosocial Integrity

D) Hildegard Peplau, the mother of psychiatric nursing, defined nursing as an interpersonal

process using the nurse-client relationship to facilitate change in the client. B.F. Skinner, a

behavioral theorist, promoted learning through the use of reinforcements and punishment as

an avenue for behavioral change. Erik Erickson, an intrapersonal theorist, saw personality and

change continuing throughout the life span. Erickson used his intrapersonal theory of

psychotherapy to help individuals return to childhood issues to finish incomplete

developmental tasks. Abraham Maslow, a social-interpersonal theorist, believed in a priority of

needs from a humanistic perspective.

Cognitive Level: Analysis

Nursing Process: Planning

Client Need: Psychosocial Integrity

10

11) The client is experiencing a crisis. Using principles of crisis theory, what is the nurse’s priority assessment?

A) The client’s social-interpersonal history

B) The length of time since the event occurred

C) The family history in relation to mental illness

D) The client’s perception of the situation

Answer: D

Explanation: A) A crisis state occurs when an event is perceived as a threat and usual resources and coping

skills are no longer effective. Eliciting the client’s perception is a priority balancing factor. The

length of time since the event, the client’s social-interpersonal history, and a family history in

relation to mental illness are not specific to balancing factors or variables that determine a

person’s potential for entering a crisis state.

Cognitive Level: Application

Nursing Process: Assessment

Client Need: Psychosocial Integrity

B) A crisis state occurs when an event is perceived as a threat and usual resources and coping

skills are no longer effective. Eliciting the client’s perception is a priority balancing factor. The

length of time since the event, the client’s social-interpersonal history, and a family history in

relation to mental illness are not specific to balancing factors or variables that determine a

person’s potential for entering a crisis state.

Cognitive Level: Application

Nursing Process: Assessment

Client Need: Psychosocial Integrity

C) A crisis state occurs when an event is perceived as a threat and usual resources and coping

skills are no longer effective. Eliciting the client’s perception is a priority balancing factor. The

length of time since the event, the client’s social-interpersonal history, and a family history in

relation to mental illness are not specific to balancing factors or variables that determine a

person’s potential for entering a crisis state.

Cognitive Level: Application

Nursing Process: Assessment

Client Need: Psychosocial Integrity

D) A crisis state occurs when an event is perceived as a threat and usual resources and coping

skills are no longer effective. Eliciting the client’s perception is a priority balancing factor. The

length of time since the event, the client’s social-interpersonal history, and a family history in

relation to mental illness are not specific to balancing factors or variables that determine a

person’s potential for entering a crisis state.

Cognitive Level: Application

Nursing Process: Assessment

Client Need: Psychosocial Integrity

12) The psychiatric-mental health nurse is developing a plan of care for a client experiencing depression. From a

cognitive theoretical framework, which of the following nursing interventions would take priority?

A) Facilitating the completion of developmental tasks

B) Reinforcing desirable behaviors and punishing undesirable behaviors

C) Challenging misperceptions and correcting misinformation

D) Encouraging use of new learning in interpersonal relationships

Answer: C

11

Explanation: A) Cognitive theory states that emotional upset and dysfunctional behaviors are related to

misperceptions and misinterpretations of experiences. Reinforcement and punishment is more

consistent with behavioral theory. Completion of developmental tasks and milestones are

central to intrapersonal theory, particularly Erickson’s theory of psychosocial development.

New learning within the context of interpersonal relationships is more congruent with

social-interpersonal theories.

Cognitive Level: Application

Nursing Process: Implementation

Client Need: Psychosocial Integrity

B) Cognitive theory states that emotional upset and dysfunctional behaviors are related to

misperceptions and misinterpretations of experiences. Reinforcement and punishment is more

consistent with behavioral theory. Completion of developmental tasks and milestones are

central to intrapersonal theory, particularly Erickson’s theory of psychosocial development.

New learning within the context of interpersonal relationships is more congruent with

social-interpersonal theories.

Cognitive Level: Application

Nursing Process: Implementation

Client Need: Psychosocial Integrity

C) Cognitive theory states that emotional upset and dysfunctional behaviors are related to

misperceptions and misinterpretations of experiences. Reinforcement and punishment is more

consistent with behavioral theory. Completion of developmental tasks and milestones are

central to intrapersonal theory, particularly Erickson’s theory of psychosocial development.

New learning within the context of interpersonal relationships is more congruent with

social-interpersonal theories.

Cognitive Level: Application

Nursing Process: Implementation

Client Need: Psychosocial Integrity

D) Cognitive theory states that emotional upset and dysfunctional behaviors are related to

misperceptions and misinterpretations of experiences. Reinforcement and punishment is more

consistent with behavioral theory. Completion of developmental tasks and milestones are

central to intrapersonal theory, particularly Erickson’s theory of psychosocial development.

New learning within the context of interpersonal relationships is more congruent with

social-interpersonal theories.

Cognitive Level: Application

Nursing Process: Implementation

Client Need: Psychosocial Integrity

13) The nurse is serving on a committee charged with reviewing the roles and responsibilities of the nurses on the

psychiatric unit. Which publication should the nurse bring to the first meeting?

A) American Nurses’ Association, Code of Ethics

B) Diagnostic and Statistical Manual of Mental Disorders

C) American Nurses’ Credentialing Center certification requirements

D) Psychiatric-Mental Health Nursing Standards of Practice

Answer: D

12

Explanation: A) The Psychiatric-Mental Health Nursing Standards of Practice, organized around the nursing

process, delineates psychiatric-mental health nursing roles and functions and serves as

guidelines for providing quality care. The Diagnostic and Statistical Manual of Mental Disorders is

used by the mental health care team to diagnose clients with mental disorders and is not

specific to nursing care issues. The Code of Ethics helps to clarify right and wrong actions by the

nurse, but does not clarify use of the nursing process, roles and nursing care actions.

Certification requirements outline steps toward certification that acknowledges knowledge and

expertise, but does not delineate roles and responsibilities.

Cognitive Level: Application

Nursing Process: Planning

Client Need: Safe, Effective Care Environment

B) The Psychiatric-Mental Health Nursing Standards of Practice, organized around the nursing

process, delineates psychiatric-mental health nursing roles and functions and serves as

guidelines for providing quality care. The Diagnostic and Statistical Manual of Mental Disorders is

used by the mental health care team to diagnose clients with mental disorders and is not

specific to nursing care issues. The Code of Ethics helps to clarify right and wrong actions by the

nurse, but does not clarify use of the nursing process, roles and nursing care actions.

Certification requirements outline steps toward certification that acknowledges knowledge and

expertise, but does not delineate roles and responsibilities.

Cognitive Level: Application

Nursing Process: Planning

Client Need: Safe, Effective Care Environment

C) The Psychiatric-Mental Health Nursing Standards of Practice, organized around the nursing

process, delineates psychiatric-mental health nursing roles and functions and serves as

guidelines for providing quality care. The Diagnostic and Statistical Manual of Mental Disorders is

used by the mental health care team to diagnose clients with mental disorders and is not

specific to nursing care issues. The Code of Ethics helps to clarify right and wrong actions by the

nurse, but does not clarify use of the nursing process, roles and nursing care actions.

Certification requirements outline steps toward certification that acknowledges knowledge and

expertise, but does not delineate roles and responsibilities.

Cognitive Level: Application

Nursing Process: Planning

Client Need: Safe, Effective Care Environment

D) The Psychiatric-Mental Health Nursing Standards of Practice, organized around the nursing

process, delineates psychiatric-mental health nursing roles and functions and serves as

guidelines for providing quality care. The Diagnostic and Statistical Manual of Mental Disorders is

used by the mental health care team to diagnose clients with mental disorders and is not

specific to nursing care issues. The Code of Ethics helps to clarify right and wrong actions by the

nurse, but does not clarify use of the nursing process, roles and nursing care actions.

Certification requirements outline steps toward certification that acknowledges knowledge and

expertise, but does not delineate roles and responsibilities.

Cognitive Level: Application

Nursing Process: Planning

Client Need: Safe, Effective Care Environment

13

14) The client is experiencing low self-esteem issues, alterations in mood, and thoughts of harming the self, in

addition to physical pain. The nurse’s priority area for assessment is:

A) Self-esteem

B) Risk of harm

C) Physical pain

D) Mood

Answer: B

Explanation: A) Safety issues take priority. The client’s safety must be ensured while the other areas of pain,

self-esteem, and mood are being assessed.

Cognitive Level: Application

Nursing Process: Assessment

Client Need: Psychosocial Integrity

B) Safety issues take priority. The client’s safety must be ensured while the other areas of pain,

self-esteem, and mood are being assessed.

Cognitive Level: Application

Nursing Process: Assessment

Client Need: Psychosocial Integrity

C) Safety issues take priority. The client’s safety must be ensured while the other areas of pain,

self-esteem, and mood are being assessed.

Cognitive Level: Application

Nursing Process: Assessment

Client Need: Psychosocial Integrity

D) Safety issues take priority. The client’s safety must be ensured while the other areas of pain,

self-esteem, and mood are being assessed.

Cognitive Level: Application

Nursing Process: Assessment

Client Need: Psychosocial Integrity

14

15) The psychiatric nurse is preparing to assess the newly admitted client with depression. Which of the following

should the nurse plan to do first?

A) Functional assessment

B) The physical assessment

C) Neuropsychiatric assessment

D) The interview

Answer: D

Explanation: A) The interview is the initial step in the assessment process unless physical needs dictate priority.

The initial interview is used to establish rapport with the client in order to enhance the

effectiveness of the other assessments which will then follow: physical assessment,

neuropsychiatric assessment, and functional assessment.

Cognitive Level: Application

Nursing Process: Assessment

Client Need: Psychosocial Integrity

B) The interview is the initial step in the assessment process unless physical needs dictate priority.

The initial interview is used to establish rapport with the client in order to enhance the

effectiveness of the other assessments which will then follow: physical assessment,

neuropsychiatric assessment, and functional assessment.

Cognitive Level: Application

Nursing Process: Assessment

Client Need: Psychosocial Integrity

C) The interview is the initial step in the assessment process unless physical needs dictate priority.

The initial interview is used to establish rapport with the client in order to enhance the

effectiveness of the other assessments which will then follow: physical assessment,

neuropsychiatric assessment, and functional assessment.

Cognitive Level: Application

Nursing Process: Assessment

Client Need: Psychosocial Integrity

D) The interview is the initial step in the assessment process unless physical needs dictate priority.

The initial interview is used to establish rapport with the client in order to enhance the

effectiveness of the other assessments which will then follow: physical assessment,

neuropsychiatric assessment, and functional assessment.

Cognitive Level: Application

Nursing Process: Assessment

Client Need: Psychosocial Integrity

15

16) The psychiatric nurses who are observing a client ask themselves if the client is a danger to self or others. What

type of observation are the nurses using?

A) Behavioral

B) Sociocultural

C) Affective

D) Cognitive

Answer: A

Explanation: A) When observing the client behaviorally, the nurse should answer the question, “Is the client a

danger to self or others?” Cognitive observations include questions dealing with the client’s

thought processes. Affective observations address the client’s subjective expressions of emotion.

Sociocultural observations deal with interpersonal relationships.

Cognitive Level: Analysis

Nursing Process: Assessment

Client Need: Psychosocial Integrity

B) When observing the client behaviorally, the nurse should answer the question, “Is the client a

danger to self or others?” Cognitive observations include questions dealing with the client’s

thought processes. Affective observations address the client’s subjective expressions of emotion.

Sociocultural observations deal with interpersonal relationships.

Cognitive Level: Analysis

Nursing Process: Assessment

Client Need: Psychosocial Integrity

C) When observing the client behaviorally, the nurse should answer the question, “Is the client a

danger to self or others?” Cognitive observations include questions dealing with the client’s

thought processes. Affective observations address the client’s subjective expressions of emotion.

Sociocultural observations deal with interpersonal relationships.

Cognitive Level: Analysis

Nursing Process: Assessment

Client Need: Psychosocial Integrity

D) When observing the client behaviorally, the nurse should answer the question, “Is the client a

danger to self or others?” Cognitive observations include questions dealing with the client’s

thought processes. Affective observations address the client’s subjective expressions of emotion.

Sociocultural observations deal with interpersonal relationships.

Cognitive Level: Analysis

Nursing Process: Assessment

Client Need: Psychosocial Integrity

16

17) The client is admitted for treatment of major depression. Along with a depressed mood, the client reports

difficulty coping with a number of recent losses. How does the nurse use this assessment data?

A) Axis IV documentation

B) Identification of DSM-IV-TR diagnostic criteria

C) Axis I documentation

D) Formulation of nursing diagnosis

Answer: D

Explanation: A) The nurse formulates nursing diagnoses using assessment data, especially signs and symptoms,

as related and contributing factors. Using signs and symptoms as diagnostic criteria within the

DSM-IV-TR and as documentation on the appropriate DSM-IV-TR axes requires collaborative

practice guidelines and falls outside the generalist nurse’s scope of independent nursing

practice.

Cognitive Level: Application

Nursing Process: Diagnosis

Client Need: Safe, Effective Care Environment

B) The nurse formulates nursing diagnoses using assessment data, especially signs and symptoms,

as related and contributing factors. Using signs and symptoms as diagnostic criteria within the

DSM-IV-TR and as documentation on the appropriate DSM-IV-TR axes requires collaborative

practice guidelines and falls outside the generalist nurse’s scope of independent nursing

practice.

Cognitive Level: Application

Nursing Process: Diagnosis

Client Need: Safe, Effective Care Environment

C) The nurse formulates nursing diagnoses using assessment data, especially signs and symptoms,

as related and contributing factors. Using signs and symptoms as diagnostic criteria within the

DSM-IV-TR and as documentation on the appropriate DSM-IV-TR axes requires collaborative

practice guidelines and falls outside the generalist nurse’s scope of independent nursing

practice.

Cognitive Level: Application

Nursing Process: Diagnosis

Client Need: Safe, Effective Care Environment

D) The nurse formulates nursing diagnoses using assessment data, especially signs and symptoms,

as related and contributing factors. Using signs and symptoms as diagnostic criteria within the

DSM-IV-TR and as documentation on the appropriate DSM-IV-TR axes requires collaborative

practice guidelines and falls outside the generalist nurse’s scope of independent nursing

practice.

Cognitive Level: Application

Nursing Process: Diagnosis

Client Need: Safe, Effective Care Environment

18) The nurse has identified a nursing diagnosis of anxiety. To assist the client to meet the outcome, “Client will

express the ability to manage anxiety consistently,” which of the following references would the nurse use to

continue the nursing process?

A) Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR)

B) Nursing Interventions Classification (NIC)

C) North American Nursing Diagnosis Association (NANDA) lists

D) Nursing Outcomes Classification (NOC)

Answer: B

17

Explanation: A) Nursing Intervention Classification (NIC) outlines standardized classifications of nursing

interventions to assist the client to meet the outcome. As the outcome has already been

developed, the Nursing Outcomes Classification (NOC) that presents a list of standardized

measures of client status on a continuum of least desirable to more desirable states or behaviors

is not needed at this time. NANDA lists that were used to assist the nurse in identifying the

nursing diagnosis of anxiety are standardized labels addressing client nursing problems. The

DSM-IV-TR is used by the mental health team to identify the client’s diagnosis for treatment

using a multi-axial system.

Cognitive Level: Application

Nursing Process: Planning

Client Need: Safe, Effective Care Environment

B) Nursing Intervention Classification (NIC) outlines standardized classifications of nursing

interventions to assist the client to meet the outcome. As the outcome has already been

developed, the Nursing Outcomes Classification (NOC) that presents a list of standardized

measures of client status on a continuum of least desirable to more desirable states or behaviors

is not needed at this time. NANDA lists that were used to assist the nurse in identifying the

nursing diagnosis of anxiety are standardized labels addressing client nursing problems. The

DSM-IV-TR is used by the mental health team to identify the client’s diagnosis for treatment

using a multi-axial system.

Cognitive Level: Application

Nursing Process: Planning

Client Need: Safe, Effective Care Environment

C) Nursing Intervention Classification (NIC) outlines standardized classifications of nursing

interventions to assist the client to meet the outcome. As the outcome has already been

developed, the Nursing Outcomes Classification (NOC) that presents a list of standardized

measures of client status on a continuum of least desirable to more desirable states or behaviors

is not needed at this time. NANDA lists that were used to assist the nurse in identifying the

nursing diagnosis of anxiety are standardized labels addressing client nursing problems. The

DSM-IV-TR is used by the mental health team to identify the client’s diagnosis for treatment

using a multi-axial system.

Cognitive Level: Application

Nursing Process: Planning

Client Need: Safe, Effective Care Environment

D) Nursing Intervention Classification (NIC) outlines standardized classifications of nursing

interventions to assist the client to meet the outcome. As the outcome has already been

developed, the Nursing Outcomes Classification (NOC) that presents a list of standardized

measures of client status on a continuum of least desirable to more desirable states or behaviors

is not needed at this time. NANDA lists that were used to assist the nurse in identifying the

nursing diagnosis of anxiety are standardized labels addressing client nursing problems. The

DSM-IV-TR is used by the mental health team to identify the client’s diagnosis for treatment

using a multi-axial system.

Cognitive Level: Application

Nursing Process: Planning

Client Need: Safe, Effective Care Environment

18

19) The client asks the psychiatric nurse if certain changes can be made in the unit milieu. What is the nurse’s best

initial action?

A) Instruct the client about the current practices within the therapeutic milieu.

B) Assess the desired changes that the client is proposing.

C) Refer the client’s requests to the psychiatrist.

D) Refer the client’s requests to the mental health team.

Answer: B

Explanation: A) The psychiatric-mental health nurse, as the milieu manager, has major responsibility for the

milieu. It is appropriate to assess (first step of the nursing process) the desired changes in order

to gather information regarding the effectiveness of the milieu. Referring the client’s requests to

others does not implement the nurse’s responsibility to use the nursing process. Any necessary

instruction (implementation) would need to follow assessment, analysis of data, and planning.

Cognitive Level: Application

Nursing Process: Implementation

Client Need: Safe, Effective Care Environment

B) The psychiatric-mental health nurse, as the milieu manager, has major responsibility for the

milieu. It is appropriate to assess (first step of the nursing process) the desired changes in order

to gather information regarding the effectiveness of the milieu. Referring the client’s requests to

others does not implement the nurse’s responsibility to use the nursing process. Any necessary

instruction (implementation) would need to follow assessment, analysis of data, and planning.

Cognitive Level: Application

Nursing Process: Implementation

Client Need: Safe, Effective Care Environment

C) The psychiatric-mental health nurse, as the milieu manager, has major responsibility for the

milieu. It is appropriate to assess (first step of the nursing process) the desired changes in order

to gather information regarding the effectiveness of the milieu. Referring the client’s requests to

others does not implement the nurse’s responsibility to use the nursing process. Any necessary

instruction (implementation) would need to follow assessment, analysis of data, and planning.

Cognitive Level: Application

Nursing Process: Implementation

Client Need: Safe, Effective Care Environment

D) The psychiatric-mental health nurse, as the milieu manager, has major responsibility for the

milieu. It is appropriate to assess (first step of the nursing process) the desired changes in order

to gather information regarding the effectiveness of the milieu. Referring the client’s requests to

others does not implement the nurse’s responsibility to use the nursing process. Any necessary

instruction (implementation) would need to follow assessment, analysis of data, and planning.

Cognitive Level: Application

Nursing Process: Implementation

Client Need: Safe, Effective Care Environment

19

20) Which of the following questions by the nurse demonstrate understanding of the nursing process step of

summative evaluation?

Select all that apply.

A) “Was the assessment completed?”

B) “Were all the interventions implemented?”

C) “Has adequate documentation of client’s progress been completed?”

D) “Were the outcome criteria demonstrated?”

E) “Were interventions effective?”

Answer: C, D, E

Explanation: A) This question should be asked during the assessment process and does nothing to measure

effectiveness of client’s progress toward outcomes and therefore is not consistent with

summative evaluation.

Cognitive Level: Analysis

Nursing Process: Evaluation

Client Need: Safe, Effective Care Environment

B) This question should be asked during the implementation process and does not measure the

issue of effectiveness in relation to client progress toward outcomes and goals and therefore is

not consistent with summative evaluation.

Cognitive Level: Analysis

Nursing Process: Evaluation

Client Need: Safe, Effective Care Environment

C) The general rule is that if it not documented, then it has not occurred. Documentation of

progress is a critical step in evaluation.

Cognitive Level: Analysis

Nursing Process: Evaluation

Client Need: Safe, Effective Care Environment

D) Evaluation is accomplished measuring client progress toward outcome criteria.

Cognitive Level: Analysis

Nursing Process: Evaluation

Client Need: Safe, Effective Care Environment

E) The effectiveness of interventions as measured by progress toward outcomes is part of the

evaluation process.

Cognitive Level: Analysis

Nursing Process: Evaluation

Client Need: Safe, Effective Care Environment

21) The nursing staff is evaluating the progress of clients toward therapeutic goals. The nursing staff realizes that

the client with the greatest risk for developing dependency is the client who has:

A) Entered into a therapeutic alliance with the nursing staff.

B) Not completed age-appropriate developmental tasks.

C) Participated in all groups and activities.

D) Had all their needs met by the nursing staff.

Answer: D

20

Explanation: A) To facilitate growth and decrease the risk for dependency in clients, nurses should not try to

meet all of the client’s needs. Clients should be supported in meeting their own needs. Entering

into a therapeutic alliance with staff enhances collaboration and the ability of the client to be

interdependent and independent as they progress toward goals. Participating in groups and

activities will equip clients for independence and lessen the risk for dependency. Incompletion

of age-appropriate developmental tasks is not specific, may lead to various client issues, and

does not necessarily increase risk for dependency. Dependency may be just one issue

depending on the specific developmental task that is unfinished.

Cognitive Level: Analysis

Nursing Process: Evaluation

Client Need: Psychosocial Integrity

B) To facilitate growth and decrease the risk for dependency in clients, nurses should not try to

meet all of the client’s needs. Clients should be supported in meeting their own needs. Entering

into a therapeutic alliance with staff enhances collaboration and the ability of the client to be

interdependent and independent as they progress toward goals. Participating in groups and

activities will equip clients for independence and lessen the risk for dependency. Incompletion

of age-appropriate developmental tasks is not specific, may lead to various client issues, and

does not necessarily increase risk for dependency. Dependency may be just one issue

depending on the specific developmental task that is unfinished.

Cognitive Level: Analysis

Nursing Process: Evaluation

Client Need: Psychosocial Integrity

C) To facilitate growth and decrease the risk for dependency in clients, nurses should not try to

meet all of the client’s needs. Clients should be supported in meeting their own needs. Entering

into a therapeutic alliance with staff enhances collaboration and the ability of the client to be

interdependent and independent as they progress toward goals. Participating in groups and

activities will equip clients for independence and lessen the risk for dependency. Incompletion

of age-appropriate developmental tasks is not specific, may lead to various client issues, and

does not necessarily increase risk for dependency. Dependency may be just one issue

depending on the specific developmental task that is unfinished.

Cognitive Level: Analysis

Nursing Process: Evaluation

Client Need: Psychosocial Integrity

D) To facilitate growth and decrease the risk for dependency in clients, nurses should not try to

meet all of the client’s needs. Clients should be supported in meeting their own needs. Entering

into a therapeutic alliance with staff enhances collaboration and the ability of the client to be

interdependent and independent as they progress toward goals. Participating in groups and

activities will equip clients for independence and lessen the risk for dependency. Incompletion

of age-appropriate developmental tasks is not specific, may lead to various client issues, and

does not necessarily increase risk for dependency. Dependency may be just one issue

depending on the specific developmental task that is unfinished.

Cognitive Level: Analysis

Nursing Process: Evaluation

Client Need: Psychosocial Integrity

21

22) The nurse is planning for the one-to-one nurse-client relationship. A goal of the introductory phase of the

therapeutic nurse-client relationship should be:

A) Increased client self-awareness.

B) Adoption of effective coping skills.

C) Identification of client outcomes.

D) Reminiscence about the nurse-client relationship.

Answer: C

Explanation: A) The introductory phase of the therapeutic relationship ends with the development of

preliminary nursing diagnoses and identification of client outcomes. Increased client

self-awareness and the adoption of more effective coping skills are accomplished within the

working phase. Reminiscence about the nurse-client relationship should occur in the

termination phase.

Cognitive Level: Application

Nursing Process: Planning

Client Need: Psychosocial Integrity

B) The introductory phase of the therapeutic relationship ends with the development of

preliminary nursing diagnoses and identification of client outcomes. Increased client

self-awareness and the adoption of more effective coping skills are accomplished within the

working phase. Reminiscence about the nurse-client relationship should occur in the

termination phase.

Cognitive Level: Application

Nursing Process: Planning

Client Need: Psychosocial Integrity

C) The introductory phase of the therapeutic relationship ends with the development of

preliminary nursing diagnoses and identification of client outcomes. Increased client

self-awareness and the adoption of more effective coping skills are accomplished within the

working phase. Reminiscence about the nurse-client relationship should occur in the

termination phase.

Cognitive Level: Application

Nursing Process: Planning

Client Need: Psychosocial Integrity

D) The introductory phase of the therapeutic relationship ends with the development of

preliminary nursing diagnoses and identification of client outcomes. Increased client

self-awareness and the adoption of more effective coping skills are accomplished within the

working phase. Reminiscence about the nurse-client relationship should occur in the

termination phase.

Cognitive Level: Application

Nursing Process: Planning

Client Need: Psychosocial Integrity

22

23) As the nurse continues to care for the client during the working phase of the therapeutic relationship, the client’s

needs change. What nursing action is appropriate at this time?

A) Reminisce about the client’s progress.

B) Restate the purpose of the relationship.

C) Address confidentiality issues.

D) Revise the plan of care as needed.

Answer: D

Explanation: A) During the working phase of the therapeutic relationship, parts of the care plan are revised,

expanded, or eliminated according to the individual client’s needs. Reminiscing about the

client’s progress generally occurs in the termination phase. Issues can be revisited, but

confidentiality and purpose are generally addressed during the introductory phase.

Cognitive Level: Application

Nursing Process: Implementation

Client Need: Psychosocial Integrity

B) During the working phase of the therapeutic relationship, parts of the care plan are revised,

expanded, or eliminated according to the individual client’s needs. Reminiscing about the

client’s progress generally occurs in the termination phase. Issues can be revisited, but

confidentiality and purpose are generally addressed during the introductory phase.

Cognitive Level: Application

Nursing Process: Implementation

Client Need: Psychosocial Integrity

C) During the working phase of the therapeutic relationship, parts of the care plan are revised,

expanded, or eliminated according to the individual client’s needs. Reminiscing about the

client’s progress generally occurs in the termination phase. Issues can be revisited, but

confidentiality and purpose are generally addressed during the introductory phase.

Cognitive Level: Application

Nursing Process: Implementation

Client Need: Psychosocial Integrity

D) During the working phase of the therapeutic relationship, parts of the care plan are revised,

expanded, or eliminated according to the individual client’s needs. Reminiscing about the

client’s progress generally occurs in the termination phase. Issues can be revisited, but

confidentiality and purpose are generally addressed during the introductory phase.

Cognitive Level: Application

Nursing Process: Implementation

Client Need: Psychosocial Integrity

23

24) Which actions taken by the nurse indicate an understanding of the role of the nursing process within the

working phase of the therapeutic relationship?

Select all that apply.

A) Planning activities

B) Conducting assessment

C) Implementation of strategies

D) Identifying outcomes

E) Evaluating effectiveness

Answer: A, B, C, D, E

Explanation: A) The nursing process is dynamic. Planning continues during the working phase.

Cognitive Level: Application

Nursing Process: Evaluation

Client Need: Psychosocial Integrity

B) The nursing process is dynamic. Assessment continues during the working phase.

Cognitive Level: Application

Nursing Process: Evaluation

Client Need: Psychosocial Integrity

C) While all steps continue, implementation is the primary step of the nursing process that occurs

during the working phase.

Cognitive Level: Application

Nursing Process: Evaluation

Client Need: Psychosocial Integrity

D) The nursing process is dynamic. Identifying outcomes continues during the working phase.

Cognitive Level: Application

Nursing Process: Evaluation

Client Need: Psychosocial Integrity

E) Formative evaluation of progress toward goals occurs during the working phase with

summative evaluation occurring primarily during the termination phase.

Cognitive Level: Application

Nursing Process: Evaluation

Client Need: Psychosocial Integrity

25) The nurse and a client with a history of abuse are working together in a one-to-one nurse-client relationship.

The nurse observes that the client is demonstrating unexplained anger toward the nurse that seems to be

without obvious cause and is out of proportion to the current situation. Which of these interpretations of the

client’s behavior might the nurse make? The client is exhibiting signs of:

A) Defense mechanisms.

B) Impaired communication.

C) Transference.

D) Countertransference.

Answer: C

Explanation: A) Transference is a client’s unconscious displacement of feelings for significant people or

relationships in the past onto the nurse in the current relationship. Countertransference is the

nurse’s emotional reaction to the client based on significant relationships in the nurse’s past.

Defense mechanisms refer to a number of thinking patterns used to decrease anxiety.

Displacement by transference is most likely occurring but the choice of defense mechanisms is

not specific enough and could refer to number of thinking patterns that are not appropriate to

this situation. The situation does not meet the defining characteristics of impaired

communication. Other nursing diagnoses would be more appropriate.

Cognitive Level: Analysis

Nursing Process: Diagnosis

Client Need: Psychosocial Integrity

24

B) Transference is a client’s unconscious displacement of feelings for significant people or

relationships in the past onto the nurse in the current relationship. Countertransference is the

nurse’s emotional reaction to the client based on significant relationships in the nurse’s past.

Defense mechanisms refer to a number of thinking patterns used to decrease anxiety.

Displacement by transference is most likely occurring but the choice of defense mechanisms is

not specific enough and could refer to number of thinking patterns that are not appropriate to

this situation. The situation does not meet the defining characteristics of impaired

communication. Other nursing diagnoses would be more appropriate.

Cognitive Level: Analysis

Nursing Process: Diagnosis

Client Need: Psychosocial Integrity

C) Transference is a client’s unconscious displacement of feelings for significant people or

relationships in the past onto the nurse in the current relationship. Countertransference is the

nurse’s emotional reaction to the client based on significant relationships in the nurse’s past.

Defense mechanisms refer to a number of thinking patterns used to decrease anxiety.

Displacement by transference is most likely occurring but the choice of defense mechanisms is

not specific enough and could refer to number of thinking patterns that are not appropriate to

this situation. The situation does not meet the defining characteristics of impaired

communication. Other nursing diagnoses would be more appropriate.

Cognitive Level: Analysis

Nursing Process: Diagnosis

Client Need: Psychosocial Integrity

D) Transference is a client’s unconscious displacement of feelings for significant people or

relationships in the past onto the nurse in the current relationship. Countertransference is the

nurse’s emotional reaction to the client based on significant relationships in the nurse’s past.

Defense mechanisms refer to a number of thinking patterns used to decrease anxiety.

Displacement by transference is most likely occurring but the choice of defense mechanisms is

not specific enough and could refer to number of thinking patterns that are not appropriate to

this situation. The situation does not meet the defining characteristics of impaired

communication. Other nursing diagnoses would be more appropriate.

Cognitive Level: Analysis

Nursing Process: Diagnosis

Client Need: Psychosocial Integrity

26) The student nurse is experiencing intense emotion toward the client for no obvious reason. Which approach by

the nursing student would be best?

A) Ignore the feelings and continue to care for the client.

B) Discuss feelings with the client.

C) Ask to change assignments.

D) Discuss feelings with the nursing instructor.

Answer: D

25

Explanation: A) Countertransference may be occurring. Discussing feelings with the instructor is the best

approach and will help bring the countertransference into conscious awareness so that the

feelings do not interfere with the ability to provide effective nursing care. Countertransference

is the student nurse’s problem, not the client’s problem; therefore, this transference would be

inappropriate to discuss with the client. The nursing student should seek to resolve personal

needs and issues outside of the nurse-client relationship. Ignored feelings may jeopardize the

effectiveness of the nursing care given to the client. Asking to change assignments does not

address the issue and denies the nursing student opportunity for personal and professional

growth. This choice also increases the probability that the feelings will surface again with

another client.

Cognitive Level: Application

Nursing Process: Implementation

Client Need: Psychosocial Integrity

B) Countertransference may be occurring. Discussing feelings with the instructor is the best

approach and will help bring the countertransference into conscious awareness so that the

feelings do not interfere with the ability to provide effective nursing care. Countertransference

is the student nurse’s problem, not the client’s problem; therefore, this transference would be

inappropriate to discuss with the client. The nursing student should seek to resolve personal

needs and issues outside of the nurse-client relationship. Ignored feelings may jeopardize the

effectiveness of the nursing care given to the client. Asking to change assignments does not

address the issue and denies the nursing student opportunity for personal and professional

growth. This choice also increases the probability that the feelings will surface again with

another client.

Cognitive Level: Application

Nursing Process: Implementation

Client Need: Psychosocial Integrity

C) Countertransference may be occurring. Discussing feelings with the instructor is the best

approach and will help bring the countertransference into conscious awareness so that the

feelings do not interfere with the ability to provide effective nursing care. Countertransference

is the student nurse’s problem, not the client’s problem; therefore, this transference would be

inappropriate to discuss with the client. The nursing student should seek to resolve personal

needs and issues outside of the nurse-client relationship. Ignored feelings may jeopardize the

effectiveness of the nursing care given to the client. Asking to change assignments does not

address the issue and denies the nursing student opportunity for personal and professional

growth. This choice also increases the probability that the feelings will surface again with

another client.

Cognitive Level: Application

Nursing Process: Implementation

Client Need: Psychosocial Integrity

D) Countertransference may be occurring. Discussing feelings with the instructor is the best

approach and will help bring the countertransference into conscious awareness so that the

feelings do not interfere with the ability to provide effective nursing care. Countertransference

is the student nurse’s problem, not the client’s problem; therefore, this transference would be

inappropriate to discuss with the client. The nursing student should seek to resolve personal

needs and issues outside of the nurse-client relationship. Ignored feelings may jeopardize the

effectiveness of the nursing care given to the client. Asking to change assignments does not

address the issue and denies the nursing student opportunity for personal and professional

growth. This choice also increases the probability that the feelings will surface again with

another client.

Cognitive Level: Application

Nursing Process: Implementation

Client Need: Psychosocial Integrity

26

27) The psychiatric-mental health nurse functions from the perspective that clients benefit from an internal locus of

control. Which client behavior demonstrates progress toward the client’s goal of operating from an internal

locus of control? The client:

A) Verbalizes that “poor” genetics is the cause of everything.

B) Asks the nurse what actions should be taken.

C) Shares feelings and treatment preferences with the nurse.

D) States the belief that God will take care of everything.

Answer: C

Explanation: A) An internal locus of control enables clients to feel empowered rather than victimized and

facilitates participation in their own healing process by sharing feelings and treatment

preferences with the nurse. Asking the nurse what actions should be taken, stating that God

will take care of everything, and verbalizing that “poor” genetics is the cause of everything are

examples of behaviors originating from an external locus of control.

Cognitive Level: Analysis

Nursing Process: Evaluation

Client Need: Psychosocial Integrity

B) An internal locus of control enables clients to feel empowered rather than victimized and

facilitates participation in their own healing process by sharing feelings and treatment

preferences with the nurse. Asking the nurse what actions should be taken, stating that God

will take care of everything, and verbalizing that “poor” genetics is the cause of everything are

examples of behaviors originating from an external locus of control.

Cognitive Level: Analysis

Nursing Process: Evaluation

Client Need: Psychosocial Integrity

C) An internal locus of control enables clients to feel empowered rather than victimized and

facilitates participation in their own healing process by sharing feelings and treatment

preferences with the nurse. Asking the nurse what actions should be taken, stating that God

will take care of everything, and verbalizing that “poor” genetics is the cause of everything are

examples of behaviors originating from an external locus of control.

Cognitive Level: Analysis

Nursing Process: Evaluation

Client Need: Psychosocial Integrity

D) An internal locus of control enables clients to feel empowered rather than victimized and

facilitates participation in their own healing process by sharing feelings and treatment

preferences with the nurse. Asking the nurse what actions should be taken, stating that God

will take care of everything, and verbalizing that “poor” genetics is the cause of everything are

examples of behaviors originating from an external locus of control.

Cognitive Level: Analysis

Nursing Process: Evaluation

Client Need: Psychosocial Integrity

27

28) The psychiatric nurse is seeking to shift from a more traditional practice to an evidence-based practice. Which

action should the nurse take first?

A) Develop a procedure that might address a specific nursing problem.

B) Link a nursing problem with outcomes and interventions.

C) Gather data reflecting a current specific nursing problem.

D) Identify what resources are available to address a nursing problem.

Answer: C

Explanation: A) Assessment is the first step of the nursing process. Identifying and gathering data reflecting a

specific nursing problem to be addressed is the first step toward evidence-based practice.

Linking a nursing problem with outcomes and interventions, developing procedures, and

identifying resources are tasks within a planning stage and reflect later steps in the process of

moving toward evidence-based practice.

Cognitive Level: Application

Nursing Process: Implementation

Client Need: Safe, Effective Care Environment

B) Assessment is the first step of the nursing process. Identifying and gathering data reflecting a

specific nursing problem to be addressed is the first step toward evidence-based practice.

Linking a nursing problem with outcomes and interventions, developing procedures, and

identifying resources are tasks within a planning stage and reflect later steps in the process of

moving toward evidence-based practice.

Cognitive Level: Application

Nursing Process: Implementation

Client Need: Safe, Effective Care Environment

C) Assessment is the first step of the nursing process. Identifying and gathering data reflecting a

specific nursing problem to be addressed is the first step toward evidence-based practice.

Linking a nursing problem with outcomes and interventions, developing procedures, and

identifying resources are tasks within a planning stage and reflect later steps in the process of

moving toward evidence-based practice.

Cognitive Level: Application

Nursing Process: Implementation

Client Need: Safe, Effective Care Environment

D) Assessment is the first step of the nursing process. Identifying and gathering data reflecting a

specific nursing problem to be addressed is the first step toward evidence-based practice.

Linking a nursing problem with outcomes and interventions, developing procedures, and

identifying resources are tasks within a planning stage and reflect later steps in the process of

moving toward evidence-based practice.

Cognitive Level: Application

Nursing Process: Implementation

Client Need: Safe, Effective Care Environment

29) The psychiatric nurse is seeking to apply evidence-based nursing practice. Which sequence best demonstrates

an understanding of the process?

A) Identify a problem, link with outcomes, and research available reliable evidence.

B) Identify a problem, develop a protocol or procedure, and get people involved.

C) Open communication channels, review research, and identify a problem for change.

D) Involve others, design a change in practice, and review the research.

Answer: A

28

Explanation: A) To help nurses shift from traditional practice to evidence-based practice, Rosswurm and

Larrabee (1999) suggests the following sequence:

· Identify a problem within nursing practice.

· Get others involved.

· Examine data that reflects the need for change.

· Link the problem with outcomes.

· Review the research.

· Design a change in practice; develop a protocol or procedure.

· Implement and evaluate

· Integrate and maintain the change by opening communication channels.

Cognitive Level: Application

Nursing Process: Evaluation

Client Need: Safe, Effective Care Environment

B) To help nurses shift from traditional practice to evidence-based practice, Rosswurm and

Larrabee (1999) suggests the following sequence:

· Identify a problem within nursing practice.

· Get others involved.

· Examine data that reflects the need for change.

· Link the problem with outcomes.

· Review the research.

· Design a change in practice; develop a protocol or procedure.

· Implement and evaluate

· Integrate and maintain the change by opening communication channels.

Cognitive Level: Application

Nursing Process: Evaluation

Client Need: Safe, Effective Care Environment

C) To help nurses shift from traditional practice to evidence-based practice, Rosswurm and

Larrabee (1999) suggests the following sequence:

· Identify a problem within nursing practice.

· Get others involved.

· Examine data that reflects the need for change.

· Link the problem with outcomes.

· Review the research.

· Design a change in practice; develop a protocol or procedure.

· Implement and evaluate

· Integrate and maintain the change by opening communication channels.

Cognitive Level: Application

Nursing Process: Evaluation

Client Need: Safe, Effective Care Environment

D) To help nurses shift from traditional practice to evidence-based practice, Rosswurm and

Larrabee (1999) suggests the following sequence:

· Identify a problem within nursing practice.

· Get others involved.

· Examine data that reflects the need for change.

· Link the problem with outcomes.

· Review the research.

· Design a change in practice; develop a protocol or procedure.

· Implement and evaluate

· Integrate and maintain the change by opening communication channels.

Cognitive Level: Application

Nursing Process: Evaluation

Client Need: Safe, Effective Care Environment

29

30) The psychiatric-mental health nursing staff is working to enhance the quality of nursing care on the unit by

applying evidence-based practice. Toward this goal, the nursing staff should collect data and information from

which of the following sources?

A) Clients’ choices and concerns

B) Personal clinical experiences

C) Nursing research

D) Policy and procedure manuals

Answer: C

Explanation: A) Nursing research is the tool by which evidence-based practices are developed, tested,

evaluated, and incorporated into nursing practice. Personal clinical experiences and client’s

choices and concerns may help to identify areas for research and change, but are not the source

for evidence-based practices. Policy and procedure manuals will only address what is

currently in place.

Cognitive Level: Application

Nursing Process: Assessment

Client Need: Safe, Effective Care Environment

B) Nursing research is the tool by which evidence-based practices are developed, tested,

evaluated, and incorporated into nursing practice. Personal clinical experiences and client’s

choices and concerns may help to identify areas for research and change, but are not the source

for evidence-based practices. Policy and procedure manuals will only address what is

currently in place.

Cognitive Level: Application

Nursing Process: Assessment

Client Need: Safe, Effective Care Environment

C) Nursing research is the tool by which evidence-based practices are developed, tested,

evaluated, and incorporated into nursing practice. Personal clinical experiences and client’s

choices and concerns may help to identify areas for research and change, but are not the source

for evidence-based practices. Policy and procedure manuals will only address what is

currently in place.

Cognitive Level: Application

Nursing Process: Assessment

Client Need: Safe, Effective Care Environment

D) Nursing research is the tool by which evidence-based practices are developed, tested,

evaluated, and incorporated into nursing practice. Personal clinical experiences and client’s

choices and concerns may help to identify areas for research and change, but are not the source

for evidence-based practices. Policy and procedure manuals will only address what is

currently in place.

Cognitive Level: Application

Nursing Process: Assessment

Client Need: Safe, Effective Care Environment

30

mental health nursing 6th edition fontaine test bank