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Test Bank Psychiatric Nursing, 8th Edition by Norman L. Keltner

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Test Bank Psychiatric Nursing, 8th Edition by Norman L. Keltner

Test Bank Psychiatric Nursing, 8th Edition by Norman L. Keltner

Chapter 01: Med, Meds, Milieu

Keltner: Psychiatric Nursing, 8th Edition

MULTIPLE CHOICE

 

  1. A newly licensed asks a nursing recruiter for a description of nursing practice in the psychiatric setting. What is the nurse recruiter’s best response?
    1. “The nurse primarily serves in a supportive role to members of the health care delivery team.”
    2. “The multidisciplinary approach eliminates the need to clearly define the responsibilities of nursing in such a setting.”
    3. “Nursing actions are identified by the institution that distinguishes nursing from other mental health professions.”
    4. “Nursing offers unique contributions to the psychotherapeutic management of psychiatric patients.”

ANS: D

Professional role overlap cannot be denied; however, nursing is unique in its focus on and application of psychotherapeutic management. Neither the facility nor the multidisciplinary team define the professional responsibilities of its members but rather utilizes their unique skills to provide holistic care. Ideally, all team members support each other and have functions within the team.

 

DIF:    Cognitive level: Analyzing             TOP: Nursing process: Implementation MSC: Client Needs: Safe, Effective Care Environment

 

  1. Which component of the nursing process will the nurse focus upon to address the responsibility to match individual patient needs with appropriate services?
  2. Planning
  3. Evaluation
  4. Assessment
  5. Implementation

ANS: C

Proper assessment is critical for being able to determine the appropriate level of services that will provide optimal care while considering patient input and at the lowest cost. Planning and implementation utilizes the assessment data to identify and execute actions (treatment plan) that will provide appropriate care. Evaluation validates the effectiveness of the treatment plan.

 

DIF:    Cognitive level: Applying           TOP: Nursing process: Assessment MSC: Client Needs: Safe, Effective Care Environment

 

  1. An adult diagnosed with paranoid schizophrenia frequent experiences auditory hallucinations and walks about the unit, muttering. Which nursing action demonstrates the nurse’s understanding of effective psychotherapeutic management of this client?
    1. Discussing the disease process of schizophrenia with the client and their domestic partner
    2. Minimizing contact between this patient and other patients to assure a stress free milieu
    3. Administering PRN medication when first observing the evidence that the client may be hallucinating
    4. Independently determining that behavior modification is appropriate to decrease the client’s paranoid thoughts

ANS: A

An understanding of psychopathology is the foundation on which the three components of psychotherapeutic management rest; it facilitates therapeutic communication and provides a basis for understanding psychopharmacology and milieu management.

Minimizing contact between the patient and others and administering PRN medication indiscriminately are nontherapeutic interventions. Using behavior modification to decrease the frequency of hallucinations would need to be incorporated into the plan of care by the care team.

 

DIF:    Cognitive level: Applying               TOP: Nursing process: Implementation MSC: Client Needs: Safe, Effective Care Environment

 

  1. An adult diagnosed with chronic depression is hospitalized after a suicide attempt. Which intervention is critical in assuring long-term, effective client care as described by psychotherapeutic management?
  2. Involvement in group therapies
  3. Focus of close supervision by the unit staff
  4. Maintaining effective communication with support system
  5. Frequently scheduled one-on-one time with nursing staff

ANS: D

A critical element of psychotherapeutic management is the presence of a therapeutic nurse-patient relationship. One-on-one time with nursing staff will help in establishing this connection. While the other options are appropriate and client centered, the

nurse-client relation is critical in the long-term delivery of quality effective care to this client.

 

DIF:    Cognitive level: Applying               TOP: Nursing process: Implementation MSC: Client Needs: Psychosocial Integrity


  1. A patient’s haloperidol dosage was reduced 2 weeks ago to decrease side effects. What assessment question demonstrates the nurse’s understanding of the resulting needs of the client?
  2. “Will you have any difficulty getting your prescription refilled?”
  3. “Have you begun experiencing any forms of hallucinations?”
  4. “What do you expect will occur since the dosage has been reduced?”
  5. “What can I do to help you manage this reduction in haloperidol therapy?”

ANS: B

It will be necessary for the nurse to assess for exacerbation of the patient’s symptoms of psychosis as well as for a lessening of side effects. Dosage decrease might lead to the return or worsening of positive symptoms such as hallucinations and delusions, and negative symptoms such as blunted affect, social withdrawal, and poor grooming. While the other options may be appropriate assessment questions, they are not directed at the current needs of the client; the identification of emerging psychotic behaviors.

 

DIF:    Cognitive level: Analyzing           TOP: Nursing process: Assessment MSC: Client Needs: Physiologic Integrity

 

  1. Which statement forms the foundation upon which a nurse should base the implementation of psychotherapeutic management to the care of a patient with mental illness?
  2. The nurse’s role in client care is supported by the multidisciplinary team.
  3. Omitting any one component will compromise the effectiveness of the treatment.
  4. The most important element of psychotherapeutic management is drug therapy.
  5. A therapeutic nurse-patient relationship is the most important aspect of treatment.

ANS: B

When one element is missing, treatment is usually compromised. No single element is more important than the others; however, patients’ needs govern the application of the components and permit judicious use. The remaining options identify components of the psychotherapeutic management process.

 

DIF:    Cognitive level: Analyzing             TOP: Nursing process: Analysis MSC: Client Needs: Safe, Effective Care Environment

 

  1. Which statement most accurately describes a nurse’s role regarding psychopharmacology?
  2. “You will need to frequently make decisions regarding the administration of PRN medications to help the client manage anger.”
    1. “It’s a nursing responsibility to adjust a medication dose to assure effective patient responses.”
    2. “Nurses administers medications while evaluating drug effectiveness is a medical responsibility.”
    3. “To best assure appropriate response, a patient’s questions about drug therapy should be referred to the psychiatrist.”

ANS: A

Nursing assessment and analysis of data might suggest the need for PRN medication as patient anxiety increases or psychotic symptoms become more acute. The nurse is the health team member who makes this determination. Nurses are responsible for monitoring drug effectiveness as well as administering medication. Nurses should assume responsibility for teaching patients about the side effects of medications. Nurses cannot alter prescribed dosages of medications unless they have prescriptive privileges.

 

DIF:    Cognitive level: Analyzing             TOP: Nursing process: Analysis MSC: Client Needs: Safe, Effective Care Environment

 

  1. When considering environmental aspects of milieu management, which intervention has the highest priority for a client admitted after a failed suicide attempt?
  2. Sending the client’s new medication prescriptions to the pharmacy
  3. Assigning a staff member to one-on-one observation of the client
  4. Orienting the client to the milieu’s public and private spaces
  5. Having all potentially dangerous items removed from the client’s belongings

ANS: B

Milieu management provides a proactive approach to care. Safety overrides all other dimensions of the milieu. Initiation of suicide precautions are the priority for this client. All the remaining options are appropriate but none protect the client from the risk of another attempt to self-harm as effectively as one-on-one observation as part of suicide precautions.

 

DIF:    Cognitive level: Analyzing             TOP: Nursing process: Implementation MSC: Client Needs: Safe, Effective Care Environment

 

  1. The implementation of which unit policy directed at milieu balance would reflect a need for reconsideration on the part of the treatment team?
  2. All clients will receive verbal and written information explaining unit rules.
    1. Unit clients will engage in all unit activities to assure interaction with both staff and other clients.
    2. All clients will be uniformly expected to present themselves in a nonviolent manner to both staff and other clients.
    3. At times of unit stress, client will return to their rooms.

ANS: B

The situation described suggests a milieu in which patients have no time for planned therapeutic encounters with staff; hence, it is a milieu lacking balance. The remaining options address unit norms, limit setting, and environmental modifications that are reasonable and will contribute to a therapeutic milieu.

 

DIF:    Cognitive level: Evaluating           TOP: Nursing process: Evaluation MSC: Client Needs: Safe, Effective Care Environment


  1. Which intervention should the nurse implement when focusing on communicating therapeutically with a client?
  2. Explaining to the client why they will need to ask for a razor
  3. Providing the client with options to help achieve smoking cessation
  4. Encouraging the client to identify personal stressors
  5. Assuring the client that they can receive telephone call on the unit telephone

ANS: C

A nurse uses therapeutic communication techniques as part of the therapeutic nurse-patient relationship. An example of such communication is providing the client with an opportunity to safely identify personal stressors. The remaining options address safety, balance, and norms associated with their care.

 

DIF:    Cognitive level: Applying               TOP: Nursing process: Implementation MSC: Client Needs: Psychosocial Integrity

 

  1. During the risk assessment phase of care for a psychiatric patient, what is the nurse’s primary goal?
  2. Making an initial assessment
  3. Confirming the patient’s problem
  4. Assessing potential dangerousness to self or others
  5. Determining the level of supervision needed for the patient

ANS: C

Risk assessment involves looking at dangerousness to self or others, the degree of disability, and whether or not the individual is acutely psychotic to determine the feasibility of community-based care versus hospital-based care. Risk assessment usually follows the initial assessment. Confirmation of the patient’s problem is not part of the risk assessment protocol. Arranging entry into the mental health system will follow risk assessment if the patient is assessed as needing service.

 

DIF:    Cognitive level: Applying           TOP: Nursing process: Assessment MSC: Client Needs: Safe, Effective Care Environment

 

  1. Risk assessment for a patient shows these findings: schizophrenia but not currently; not a danger to self or others; lives in parents’ home. Which decision regarding placement on the continuum of care is appropriate?
  2. Hospitalize the patient.
  3. Discharge the patient from the system.
  4. Refer the patient to outpatient services.
  5. Refer the patient to self-help resources in the community.

ANS: C

Referral should be made to the least restrictive, most effective, and most cost-conscious source of services. Because the patient is not a danger to self or others, hospitalization is not needed. However, follow-up as an outpatient would be more appropriate than referral to a self-help group, in which structure might be lacking, or discharge from the system.

 

DIF:    Cognitive level: Applying               TOP: Nursing process: Planning MSC: Client Needs: Safe, Effective Care Environment

 

  1. A patient tells the nurse, “This medicine makes me feel weird. I don’t think I should take it anymore. Do you?” The most effective reply that the nurse could make is based on which psychotherapeutic management model?
  2. Psychopathology
  3. Milieu management
  4. Psychopharmacology
  5. Therapeutic nurse-patient relationship

ANS: C

Concerns about medication voiced by patients require the nurse to have knowledge about psychotherapeutic drugs to make helpful responses. The nurse-patient relationship component is based on use of self. Milieu management is concerned with the environment of care. Psychopathology provides foundational knowledge of mental disorders but would be less relevant in framing a response to the patient than knowledge of psychopharmacology.

 

DIF:    Cognitive level: Analyzing             TOP: Nursing process: Implementation MSC: Client Needs: Physiologic Integrity

 

  1. A patient tells the nurse, “This medication makes me feel weird. I don’t think I should take it anymore. Do you?” What is the nurse’s best response?
  2. “I wonder why you think that.”
  3. “Tell me how the medication makes you feel.”
  4. “One must never stop taking medication.”
  5. “You need to discuss this with your psychiatrist.”

ANS: B

As part of the psychopharmacology component of psychotherapeutic management, the responsibility of the nurse is to gather data about patients’ responses to medication and to be alert for side and adverse effects of the medication. The other responses are tangential to the real issue.

 

DIF:    Cognitive level: Applying               TOP: Nursing process: Implementation MSC: Client Needs: Physiologic Integrity


  1. The spouse of a patient with panic attacks tells the nurse, “I am afraid my husband has a permanent disorder and will have many hospitalizations in the future. I wonder how I will be able to raise our children alone.” The nurse’s reply should be based on which form of nursing knowledge?
  2. Psychopathology
  3. Milieu management
  4. Psychopharmacology
  5. Nursing relationship therapy

ANS: A

An understanding of psychopathology will enable the nurse to communicate reassurance to the spouse regarding the treatment of panic attacks in an outpatient setting. None of the other options has psychotherapeutic knowledge of psychiatric disorders as its focus.

 

DIF:    Cognitive level: Applying               TOP: Nursing process: Implementation MSC: Client Needs: Psychosocial Integrity

 

  1. Which observation during morning rounds should receive a nurse’s priority attention?
  2. Breakfast is late being served.
  3. A sink is leaking, leaving water on the bathroom floor.
  4. The daily schedule has not been posted on the unit bulletin board.
  5. A small group of patients is complaining that one patient turned down the TV volume.

ANS: B

Safety is the component of therapeutic milieu management that takes priority over the other components. A patient could be injured if he or she slipped and fell. The other problems do not pose a threat to patient safety.

 

DIF:    Cognitive level: Analyzing             TOP: Nursing process: Planning MSC: Client Needs: Safe, Effective Care Environment

 

  1. A community mental health nurse assessing a person with a psychiatric disorder, should refer this person to services based on which basic concept?
  2. Focus on interventions is on the least costly initially.
  3. Initial interventions are the least restrictive.
  4. Initial interventions offer a form of psychoeducation.
  5. Rapid symptom stabilization is the primary goal.

ANS: B

The concept of least restrictive treatment environment preserves individual rights to freedom. Many patients are healthy enough to receive community-based treatment. Hospitalization is reserved for short periods when patients are assessed as being a danger to self or others. Cost is a consideration but is of lesser concern than safety. All facets of the continuum should offer psychoeducation as needed by patients and families. Some aspects of the care continuum are more concerned with a patient’s need for symptom stabilization than others (e.g., hospitals versus psychiatric rehabilitation programs). The outcome of symptom stabilization is not a need for some patients, so it is not a correct answer.

 

DIF:    Cognitive level: Analyzing             TOP: Nursing process: Implementation MSC: Client Needs: Safe, Effective Care Environment

 

  1. An acutely psychotic patient is restricted to an inpatient unit. This intervention demonstrates that which milieu element has been adapted?
  2. Norms
  3. Balance
  4. Therapy
  5. Psychopathology

ANS: B

Balance refers to negotiating the line between dependence and independence. The more psychotic the individual, the less independence he or she can usually handle safely. Unit restriction with careful supervision by staff helps compensate for lack of patient judgment. Norms refers to behavioral expectations for patients. Therapy is provided by advanced-practice nurses or others with advanced education and so is not an element of milieu management. Psychopathology is not considered an environmental element.

 

DIF:    Cognitive level: Analyzing             TOP: Nursing process: Implementation MSC: Client Needs: Safe, Effective Care Environment

 

  1. An individual diagnosed with schizophrenia has a history of medication nonadherence. When inpatient psychiatric care is not indicated, which service is the preferred referral?
  2. Primary care
  3. Outpatient counseling
  4. Apartment residential living
  5. A group home with 24-hour supervision

ANS: D

Although inpatient hospitalization is unnecessary, the individual requires an environment in which medication compliance can be fostered. In this case, the group home would provide the best alternative. The other options do not provide adequate supervision.

 

DIF:    Cognitive level: Analyzing             TOP: Nursing process: Planning MSC: Client Needs: Safe, Effective Care Environment


  1. A patient diagnosed with bipolar disorder has stabilized and is being discharged from the hospital. The patient will live independently at home but lacks social skills and transportation. Which referral would be most appropriate?
  2. A group home
  3. A self-help group
  4. A day treatment program
  5. Assertive community treatment (ACT)

ANS: D

Assertive community treatment (ACT) provides intensive supervision, which includes assistance with medications and transportation that would support the goal of minimizing future hospitalizations. A group home is unnecessary, because the patient will reside at home. A day treatment program would provide a therapeutic program directed toward symptoms, but the patient’s symptoms have stabilized so this service is not indicated. A self-help group would not provide the intensity of service this patient needs.

 

DIF:    Cognitive level: Analyzing             TOP: Nursing process: Planning MSC: Client Needs: Safe, Effective Care Environment

 

  1. A patient diagnosed with long-standing bipolar disorder comes to the mental health center. The patient says, “I lost my job and home. Now, I eat in soup kitchens and sleep at a shelter. I am so depressed that I thought about jumping from a railroad bridge into a river.” Which factor has priority for the nurse who determines the appropriate level of care?
  2. Long-standing bipolar disorder
  3. Risk for suicide
  4. Homelessness
  5. Lack of income

ANS: B

Risk assessment shows the patient to have suicidal thoughts, and a plan for the suicide that is highly lethal, executable, and with low potential for rescue. The other factors do not have as great an effect on the determination of the level of services needed since they are less related to acute safety.

 

DIF:    Cognitive level: Analyzing           TOP: Nursing process: Evaluation MSC: Client Needs: Safe, Effective Care Environment

 

  1. When explaining risk assessment, the nurse would indicate that the highest priority for admission to hospital-based care is associated with which goal?
  2. Safety of self and others
  3. Minimal confusion and disorientation
  4. Successful withdrawal from harmful substances
  5. Management of medical illness complicating a psychiatric disorder

ANS: A

The highest priority is safety. In the other situations, threats to safety might or might not exist.

 

DIF:    Cognitive level: Analyzing             TOP: Nursing process: Implementation MSC: Client Needs: Safe, Effective Care Environment

 

  1. What explanation regarding the unit milieu would be most important for the nurse to give to a newly admitted patient?
  2. “Your behavior will be carefully monitored during your hospital stay.”
  3. “Unit activities will help you cope with immediate needs and stressors.”
  4. “You will be given enough medication to bring your symptoms under control.”
  5. “I will be gathering information about you to plan your care and your discharge.”

ANS: B

This choice best reflects the purpose of milieu management in psychotherapeutic management as demonstrated through unit activities. Stating that behavior will be monitored creates suspicion. Discussing medication administration is a psychopharmacology issue and is not pertinent to unit milieu. Stating that assessment will take place is not directly related to milieu.

 

DIF:    Cognitive level: Analyzing             TOP: Nursing process: Implementation MSC: Client Needs: Psychosocial Integrity

 

  1. Referral to a psychiatric extended-care facility would be most appropriate for which of the following patients?
  2. An adult with generalized anxiety disorder
  3. A severely depressed 70-year-old retiree
  4. A patient with personality disorder who frequently self-mutilates
  5. A severely ill person with schizophrenia who is regressed and withdrawn

ANS: D

Extended care often serves those with severe and persistent mental illness and those with a combination of psychiatric and medical illnesses. The patient demonstrating the signs and symptoms described in the correct option is at risk for developing psychotic behaviors that increases the risk for self and other directed harm. Patients with anxiety disorders can be referred to outpatient services. Severely depressed patients would need more intensive care, as would a self-mutilating individual.

 

DIF:    Cognitive level: Analyzing             TOP: Nursing process: Analysis MSC: Client Needs: Safe, Effective Care Environment


MULTIPLE RESPONSE

 

  1. What data should a nurse analyze when deciding to refer a patient with a psychiatric disorder to community-based care? (Select all that apply.)
  2. Need for PRN medication
  3. Severity of the patient’s illness
  4. Need for structured formal therapy
  5. Presence of suicidal or homicidal ideation
  6. Amount of supervision required by the patient

ANS: B, D, E

The decision tree for the continuum of care calls for the assessment of severity of the illness, the presence or absence of suicidal or homicidal ideation, whether or not the disability is so great that the patient is unable to provide for his or her own basic needs, and the amount of supervision required for patient safety. The frequency of need for PRN medication and the need for structured formal therapy are not considerations mentioned in the decision tree.

 

DIF:    Cognitive level: Analyzing             TOP: Nursing process: Planning MSC: Client Needs: Safe, Effective Care Environment

 

  1. Which intervention demonstrates that a nurse is functioning within the scope of psychotherapeutic management? (Select all that apply.)
  2. Structuring meaningful unit activities
  3. Administering electroconvulsive therapy
  4. Encouraging a patient to express feelings
  5. Interpreting the results of psychological testing
  6. Assessing a patient for medication side effects

ANS: A, C, E

Milieu management, patient communication, and medication administration are all within the scope of nursing practice. Electroconvulsive therapy is a medical treatment and, therefore, should be administered by a physician. Psychological testing is interpreted by a psychologist.

 

DIF:    Cognitive level: Analyzing             TOP: Nursing process: Implementation MSC: Client Needs: Safe, Effective Care Environment