Question 1

The nurse is caring for a patient with a major depressive disorder who tells the nurse that she is unable to leave her house and stays in bed most days of the week. When planning care for this patient, what priority nursing diagnosis will the nurse formulate?

Accepted Answer

2. The priority nursing diagnosis is social isolation due to depression, as evidenced by the inability to leave the house. While the patient may be experiencing chronic fatigue, this is not the priority nursing diagnosis. All nursing diagnoses are formulated the same way: A problem is identified, and the words "due to" are used, followed by the causative agent. The words "as evidenced by" are then used, followed by the patient's manifestations or presenting symptoms.

Question 2

The nurse is caring for a patient with bipolar disorder who has been awake for 72 hours and has eaten only small amounts of food. The patient's speech is pressured and unorganized. When planning care for this patient, what priority nursing diagnosis will the nurse formulate?

Accepted Answer

4. The priority nursing diagnosis for the patient is risk for injury due to acute mania, as evidenced by altered nutrition, dry oral membranes, decreased sleep, and pressured speech. The patient who is experiencing acute mania is at risk for injury due to alterations of nutrition and sleep. While the patient with acute mania is experiencing an alteration of sleeping pattern, this is not the priority nursing diagnosis. All nursing diagnoses are formulated the same way: A problem is identified, and the words "due to" are used, followed by the causative agent. The words "as evidenced by" are then used, followed by the patient's manifestations or presenting symptoms.

Question 3

The nurse who is caring for a patient with mental illness has performed the nursing assessment and formulated the nursing diagnosis. What is the purpose of the next phase of the nursing process?

Accepted Answer

2. The next phase of the nursing process in the planning phase. During this phase, the nurse establishes measurable goals and outcomes is order to plan for appropriate interventions. The mental status assessment occurs during, not after, the nursing assessment. Implementation and evaluation occur after the planning phase.

Question 4

The nurse is evaluating the goals and outcomes of patient who is being discharged with a diagnosis of major depressive disorder. Why is the met versus not-met framework of evaluating goals and outcomes not the most effective method, though it is the most widely used method?

Accepted Answer

4. The met versus not-met framework of evaluating goals and outcomes, though the most widely used method, is less effective at specifying progress toward meeting the goal or outcome. Evaluation methods do not identify, define, or document specific goals.

Question 5

The nurse is caring for a patient diagnosed with anxiety. Which is the priority for assessment for a patient with anxiety?

Accepted Answer

1. The nurse's priority is always patient safety. Once the patient's safety has been assessed, the nurse continues the assessment.

Question 6

The nurse is planning care for a patient who is in the recovery phase of illness. The nurse knows which is a focus of care for a patient in the recovery phase of illness?

Accepted Answer

3. Patients' needs vary according to their acuity and stage of illness. In the recovery phase, nurses can focus on patients' coping skills and problem solving abilities. In the crisis stage, nurses focus on patient safety and stability of symptoms. In the acute illness stage, nurses assess the extent to which the patient's symptoms affect quality of living.

Question 7

When reviewing the plan of care for a patient with mental illness, the nurse notes that the patient is not meeting one of the established goals. What is the nurse's best action?

Accepted Answer

1. When a patient is not progressing towards a goal or outcome, the nurse should collaborate with the patient, if possible, to reassess the plan of care. While the nurse is constantly collaborating with the health care provider and members of the health care team, the nurse does not collaborate with the health care provider to reassess the patient's plan of care. The nurse will not change the plan of care prior to attempting to collaborate with the patient to reassess the plan of care.

Question 8

The nurse is caring for a patient with acute mania and is planning appropriate goals and outcomes for the patient's care. Which goal meets all the requirements for a properly-stated patient goal?

Accepted Answer

1. Properly stated patient goals must be concrete and measurable. The goal that the patient will sleep 6 hours a night within 3 days meets these requirements of properly-stated goals. The goal of a "normal" mood pattern is not measurable, as "normal" is different for everyone. Assessing the patient for acute mania and providing the patient meals are nursing actions, not patient goals.

Question 9

The nurse is planning care for a patient with mental illness. What is true regarding patient goals?

Accepted Answer

3. Goals and outcomes are mutually-agreed upon with the patient and nurse. These goals should be concrete and measurable, in order to track progress. While goals should be clear and detailed, they should not be open-ended, general, or standard.

Question 10

The nurse is caring for a patient with mental illness who tells the nurse, "I can't sleep anymore." What is the nurse's best response?

Accepted Answer

2. The nurse should use clarification and open-ended questions when replying to the patient. Asking the patient, "You have trouble sleeping?" clarifies the patient's statement and is an open-ended question. The other questions are closed-ended questions and are not the best response to the patient's initial statement.

Question 11

The nurse is evaluating the goals and outcomes of a patient with mental illness. What is the purpose of a patient-specific outcome?

Accepted Answer

3. The purpose of a patient-specific outcome is to allow the nurse to define the particular steps made toward improved health. Assessment, diagnosis, and interventions are performed prior to the evaluation stage.

Question 12

The nurse is performing a nursing assessment on a patient who is diagnosed with severe mental illness. Which type of intervention best illustrates the nurse's action?

Accepted Answer

1. In some care plans, interventions are organized according to the "type" of intervention: diagnostic, therapeutic, or educational. These categories can be helpful when the nurse is planning care to include interventions of each type to address the problem. Diagnostic interventions involve assessment and evaluative actions by the nurse. Assessment is not categorized as therapeutic or educational.

Question 13

The nurse is planning care for a newly admitted patient with mental illness. According to the nursing process, what is the nurse's next action, after formulating the patient's nursing diagnosis?

Accepted Answer

2. Once the nurse has formulated the patient's nursing diagnosis, the nurse will identify problems and their priority in care. This occurs during the planning phase of the nursing process. Assessment occurs prior to diagnosis. Implementation and evaluation occur after planning.

Question 14

The nurse is caring for a patient with schizophrenia who is experiencing auditory hallucinations. The patient tells the nurse, "The voices in my head are telling me to do things that I don't want to do." When planning care for this patient, what is the priority nursing diagnosis that the nurse will formulate?

Accepted Answer

2. The priority nursing diagnosis is risk for violence due to auditory hallucinations, as evidenced by command hallucinations. The patient who is having command auditory hallucinations is also experiencing disturbed thought processes; however, this is not the priority nursing diagnosis. All nursing diagnoses are formulated the same way: A problem is identified, and the words "due to" are used, followed by the causative agent. The words "as evidenced by" are then used, followed by the patient's manifestations or presenting symptoms.

Question 15

The nurse is caring for a patient with schizophrenia who is recovering from open abdominal surgery. The nurse observes the patient grimacing and guarding his abdomen. From the information provided, what priority nursing diagnosis will the nurse formulate for this patient?

Accepted Answer

2. Acute pain due to surgery, evidenced by facial grimacing, tachycardia, and tachypnea is the priority nursing diagnosis for this patient. All nursing diagnoses are formulated the same way: A problem is identified and the words "due to" are used, followed by the causative agent. The words "as evidenced by" are then used, followed by the patient's manifestations or presenting symptoms. While the patient has schizophrenia, the clinical scenario does not indicate that the patient is having disturbed thought processes. The priority nursing diagnosis addresses the patient's basic need of pain relief.

Question 16

The nurse is planning care for a patient with severe mental illness who tells the nurse, "I am sad all the time and I don't have any motivation to keep going." Which nursing intervention takes priority?

Accepted Answer

3. Because the patient is expressing hopelessness by saying "I don't have any motivation to keep going," the priority is to assess the patient for suicidal ideation. The patient has not expressed disturbed sleep patterns, so this is not a priority. While it is important for the nurse to instill hope and empathy, these are not the priority interventions for this patient.

Quiz 9: The Nursing Process in Psychiatric-Mental Health Nursing