Varcarolis: Foundations of Psychiatric Mental Health Nursing: A
Clinical Approach, 5th Edition
Test Bank
Chapter 6: Mental Health Nursing in Community Settings
MULTIPLE CHOICE
1) Nurse A works in an inpatient unit in the community mental health center. Nurse B is a community mental health nurse. To provide comprehensive care to clients, which skill must nurse B use that nurse A does not currently use?
| A. | A calm external manner |
| B. | Problem-solving skills |
| C. | Ability to cross service systems |
| D. | Knowledge of psychopharmacology |
ANS: C
A community mental health nurse must be able to work with schools, corrections facilities, shelters, health care providers, and employers. The mental health nurse working in an inpatient unit needs only to be able to work within the single setting. Option A: This manner would be needed by nurses in both settings. Option B: Problem-solving skills are needed by all nurses. Option D: Nurses in both settings must have knowledge of psychopharmacology.
DIF: Cognitive Level: Analysis REF: Text Page: 89
TOP: Nursing Process: Implementation
MSC: NCLEX: Safe, Effective Care Environment;
2) The community mental health nurse calls on a highly suspicious psychiatric client, saying “I’m a nurse from the mental health center. I’d like to come in and find out how you’re doing.” The client refuses to allow the nurse access to her apartment, saying “My neighbor talks to me every day. I don’t know you. You could be from the IRS or the CIA. The less you know about me, the better.” The best initial intervention for the nurse to take to try to gain access would be to
| A. | ask the client’s neighbor to go with her. |
| B. | have the police accompany her. |
| C. | deny a relationship with the IRS or CIA. |
| D. | mention the client will have to go to the hospital unless she sees the nurse. |
ANS: A
Having a person the client trusts intercede on the nurse’s behalf may smooth the way for the nurse and client to develop a trusting relationship. Option B: This measure would be a last resort. Option C: This would be ineffective because of the client’s high level of suspicion. Option D: This is a threat that could be construed as an assault.
DIF: Cognitive Level: Application REF: Text Page: 86, Text Page: 87
TOP: Nursing Process: Implementation
MSC: NCLEX: Safe, Effective Care Environment;
3) A desirable treatment outcome for a seriously mentally ill client in an inpatient setting might be that “The client will show stabilization of symptoms and return to the community.” In contrast, an identified outcome for a seriously mentally ill client being treated in a community setting should be that “The client will demonstrate
| A. | the ability to maintain stability in the community.” |
| B. | an absence of symptoms and improved level of functioning.” |
| C. | functioning at a moderate to high level of social integration.” |
| D. | socially acceptable interactions within the community, good self-care, and adequate nutrition.” |
ANS: A
Symptoms often worsen when the client is discharged from the hospital and no longer has the support and structure of the hospital setting. The client can remain in the community if he or she can cope with the symptoms and situational demands (i.e., maintain stability). The goals listed in the other options are unrealistically high.
DIF: Cognitive Level: Application REF: Text Page: 88
TOP: Nursing Process: Planning (Outcome Identification)
MSC: NCLEX: Psychosocial Integrity
4) Which intervention strategy would the community psychiatric nurse include when planning care for a mentally ill client being cared for in the community?
| A. | Enforce boundaries by way of seclusion. |
| B. | Develop a long-term relationship. |
| C. | Administer prescribed medication three times daily. |
| D. | Provide three nutritious meals with snacks between meals. |
ANS: B
A long-term relationship is necessary to care for clients in the community because the time span of care is lengthy. Because hospitalizations are currently so brief, establishing a short-term relationship is all that can be expected. Options A, C, and D are interventions that would occur in the hospital rather than in the community.
DIF: Cognitive Level: Application REF: Text Page: 88
TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity
5) A client states “I don’t understand all these levels of nurses.” Which reply provides the client with accurate information? “In contrast to the role of the psychiatric nurse prepared to provide basic and direct nursing care, the advanced practice psychiatric mental health nurse is exclusively able to
| A. | provide mental health care if under the direct supervision of a physician.” |
| B. | contract to provide mental health services for individuals or groups.” |
| C. | participate in research projects if protocols have been approved by senior researchers.” |
| D. | assist with medication management but not actually prescribe it.” |
ANS: B
The only exclusive role of the advanced practice nurse mentioned in the options is contracting to provide mental services to individuals or groups. Options A, C, and D are functions the nurse with basic preparation can perform.
DIF: Cognitive Level: Application REF: Text Page: 88
TOP: Nursing Process: Implementation
MSC: NCLEX: Safe, Effective Care Environment;
6) The community psychiatric nurse learns that a suspicious and socially isolated client who lives alone chooses to eat one meal a day at a nearby soup kitchen and spend the remainder of his daily food allowance on cigarettes. The nurse’s initial action should be to
| A. | tell the client he must stop smoking to save money. |
| B. | assess weight and determine foods and amounts eaten. |
| C. | report the situation to the manager of the soup kitchen. |
| D. | seek rehospitalization for the client while a new plan is put into place. |
ANS: B
Assessment of biopsychosocial needs and general ability to live in the community is called for before any action is taken. Both nutritional status and income adequacy are critical assessment parameters. Option A: This demand would probably be ignored. Remember, a client may be able to maintain adequate nutrition while eating only one meal a day. Option C: The rule is to assess before taking action. Option D: Hospitalization may not be necessary.
DIF: Cognitive Level: Application REF: Text Page: 87, Text Page: 88
TOP: Nursing Process: Assessment MSC: NCLEX: Physiologic Integrity
7) The community psychiatric nurse notes that a client with schizophrenia has remained stable in the community for 6 weeks after discharge from the hospital. Two weeks after making this notation in the medical record, the nurse is called by the client’s husband to say that the client is delusional and explosive. During the home visit the nurse learns that the client is willing to take medication, but when her 90-day supply ran out she had none to take. The nurse arranges for a prescription refill. To avoid recurrence of this situation
| A. | the nurse will obtain the prescription refill every 90 days and deliver it to the client. |
| B. | the client’s husband will mark dates to obtain prescription refills on the calendar. |
| C. | the client will report to the hospital for medication follow-up every week. |
| D. | the client will call the nurse weekly to discuss medication-related issues. |
ANS: B
The nurse will attempt to use the client’s support system to meet client needs whenever possible. Option A should be unnecessary for the nurse to do if client or a significant other can be responsible. Option C: The client may not need more intensive follow-up as long as she continues to take medication as prescribed. Option D: This is probably unnecessary because no client issues except failure to obtain medication refill were identified.
DIF: Cognitive Level: Application REF: Text Page: 88
TOP: Nursing Process: Planning
MSC: NCLEX: Safe, Effective Care Environment;
8) The nurse assigned to an assertive community treatment program should explain the program’s treatment goals as
| A. | assisting clients to maintain abstinence from alcohol and other substances of abuse. |
| B. | maintaining medications and stable psychiatric status for incarcerated inmates who have a history of mental illness. |
| C. | providing assessment and intervention for mentally ill individuals who would otherwise have no access to care. |
| D. | providing structure and a therapeutic milieu for mentally ill clients whose symptoms require stabilization. |
ANS: C
A mobile health care unit cares for individuals who would not come to a treatment facility or an established site. Assessment and intervention are the primary aspects of the nursing process used. Little time for extensive planning and little opportunity for evaluation of outcomes exist. Option A is a goal relevant to a substance abuse treatment program. Option B is a goal relevant to a forensic setting. Option D is a goal of an inpatient unit.
DIF: Cognitive Level: Application
REF: Text Page: 92, Text Page: 93, Text Page: 94
TOP: Nursing Process: Planning
MSC: NCLEX: Safe, Effective Care Environment;
9) The nurse assigned to the assertive community treatment program is responsible for determining the location of a new inner city site for a 3-hour block of time each Tuesday. The nurse has learned the following facts: A conference room is available on the sixth floor of city hall as well as a large lobby area on the first floor, either of which could each be used as a site between 9 AM and noon. City police have been successful in clearing homeless individuals from a two-block area around city hall. A firehouse near city hall has offered a room that could be used on alternate Tuesdays from 2 to 5 PM. A fast-food restaurant located approximately four blocks from city hall is willing to allow use of its “party room” from 7 to 10 AM. The most preferable site would be the
| A. | city hall conference room. |
| B. | city hall lobby. |
| C. | firehouse room. |
| D. | restaurant “party room.” |
ANS: D
The room in the fast-food restaurant is preferable because it could be used consistently each week and because inner city residents, including those from the homeless shelter, could go there without interference.
DIF: Cognitive Level: Analysis
REF: Text Page: 92, Text Page: 93, Text Page: 94
TOP: Nursing Process: Planning
MSC: NCLEX: Safe, Effective Care Environment;
10) A community mental health nurse has been working for 6 months to establish a trusting relationship with a delusional and suspicious client. The client recently lost his job, stopped taking medication because he had no money, and then decompensated. The client states “only a traitor would make me go to the hospital.” The nurse must decide whether to arrange for hospitalization or try to provide medication so he can remain at home. The solution most in keeping with current practices in health care calls for
| A. | hospitalization for up to a week. |
| B. | negotiating a way to provide medication. |
| C. | hospitalization until he is asymptomatic. |
| D. | arranging for a bed in a homeless shelter. |
ANS: B
Although no absolutely “right” answer exists, hospitalization will damage the nurse-client relationship even if it provides an opportunity for rapid stabilization. If medication can be obtained and restarted, the client can possibly be stabilized in the home setting, even if it takes a little longer. Option D: A homeless shelter is inappropriate and unnecessary.
DIF: Cognitive Level: Analysis REF: Text Page: 86
TOP: Nursing Process: Planning
MSC: NCLEX: Safe, Effective Care Environment;
11) An activity a nurse engaged exclusively in community-based primary prevention would implement is
| A. | substance abuse counseling. |
| B. | teaching parenting skills. |
| C. | medication follow-up. |
| D. | depression screening. |
ANS: B
Primary prevention activities are directed to healthy populations to provide information for developing skills that will result in preventing mental illness. The other options are secondary prevention activities.
DIF: Cognitive Level: Application REF: Text Page: 86
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
12) A Vietnamese immigrant is a student at the local community college nursing program. The nursing instructor is concerned because the student has poor eye contact and has difficulty asking the direct questions necessary for client assessment. The nursing instructor arranges for the student to be assessed by the nurse practitioner in the college health service. This action reflects
| A. | appropriate secondary prevention by the instructor. |
| B. | insufficient understanding of the student’s culture. |
| C. | a violation of the student’s civil rights. |
| D. | prejudice and discrimination. |
ANS: B
In the student’s culture making eye contact can be perceived as disrespectful. In addition, asking direct questions may seem to the student to be intrusive and disrespectful. Option A: This behavior is not symptomatic of psychiatric illness; thus referral is inappropriate. Option C: Referral does not violate civil rights, although it is insensitive on the part of the nursing instructor. Option D: No evidence exists that the instructor was prejudiced rather than uninformed.
DIF: Cognitive Level: Analysis REF: Text Page: 87, Text Page: 88
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
13) A client who has serious and persistent symptoms of schizophrenia lives in the community. On a home visit, the community psychiatric nurse case manager learns that the client:
- Will begin attending an activities group at the mental health outreach center
- Is worried that he may not have enough money to pay for the therapy
- Does not know how to get from home to the outreach center
- Has an appointment to have blood work at the same time the activities group meets
The task listed below that is outside the coordinating role of the nurse would be
| A. | negotiating the cost of therapy for the client. |
| B. | rearranging conflicting care appointments. |
| C. | arranging transportation to the outreach center. |
| D. | monitoring to ensure that client needs are met. |
ANS: A
The actions mentioned in options B, C, and D reflect the coordinating role of the community psychiatric nurse case manager. Negotiating the cost of therapy is an intervention the nurse would not be expected to undertake.
DIF: Cognitive Level: Application REF: Text Page: 89
TOP: Nursing Process: Implementation
MSC: NCLEX: Safe, Effective Care Environment;
14) The assessment data item more relevant for the community psychiatric health nurse than the hospital-based psychiatric nurse for planning client interventions is
| A. | history of mental illness in the family. |
| B. | culturally related psychotropic dosing. |
| C. | financial status of the client. |
| D. | physical state of the client. |
ANS: C
The financial status of the client determines the viability of certain interventions in the community but is of little or no concern when determining a program of in-hospital treatment. The family history of mental illness, the physical status of the client, and culturally related dosage differences for psychotropic drugs would be of equal concern to the nurse in the hospital and the nurse in the community.
DIF: Cognitive Level: Application REF: Text Page: 87, Text Page: 88
TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity
15) The community psychiatric nurse is attempting to facilitate medication compliance for a client by having the physician prescribe depot medication that will be given by injection every 3 weeks at the community mental health outreach clinic. For this plan to be successful, what factor will the nurse assess as being of critical importance?
| A. | The attitude of significant others toward the client |
| B. | Nutrition services in the client’s neighborhood |
| C. | A trusting relationship between the client and the nurse |
| D. | The availability of transportation to the clinic |
ANS: D
The ability of the client to get to the clinic is of paramount importance to the success of the plan. The depot medication relieves the client of the necessity to take medication daily, but if he or she does not receive the injection at 3-week intervals, noncompliance will again be the issue. Options A, B, and C: Attitude toward the client, trusting relationships, and nutrition are important but not fundamental to this particular problem.
DIF: Cognitive Level: Analysis REF: Text Page: 86, Text Page: 87
TOP: Nursing Process: Assessment
MSC: NCLEX: Safe, Effective Care Environment;
16) The community psychiatric nurse makes a home visit to see a client who is scheduled to receive home care. The nurse notes the client and family make poor eye contact and that the client and all members of the family deferred to the father to answer questions during the visit. In what sphere does the explanation for this observation probably reside?
| A. | Physical |
| B. | Cultural |
| C. | Environmental |
| D. | Psychopathological |
ANS: B
Eye contact and family patterns of authority are often culturally determined. The other options are much less likely to provide a plausible explanation of the observation. Option A: All parties are physically able to communicate. Option C: The environment is identical for all possible speakers. Option D: No mention of psychopathology for any family members is given.
DIF: Cognitive Level: Application REF: Text Page: 87, Text Page: 88
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity
17) Outcomes established with the mentally ill client in the community compared with those planned for a hospitalized client will
| A. | involve a longer time frame. |
| B. | require more psychoeducation. |
| C. | have greater focus on symptom absence. |
| D. | be more concerned with medication management. |
ANS: A
Community care is concerned with long-term outcomes, whereas hospital care is concerned with short-term outcomes. Options B and D: Planning in either setting would be equally concerned with medication management and necessary psychoeducation. Option C: Planning in either setting would probably not set goals for absence of symptoms, which might be unrealistic.
DIF: Cognitive Level: Analysis REF: Text Page: 88
TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity
18) Nurse extenders in the hospital are called psychiatric technicians or nursing assistants. Whom should the nurse identify as extenders in community psychiatric care?
| A. | Pharmacists |
| B. | Social workers |
| C. | Psychiatrists and psychologists |
| D. | Supportive or concerned acquaintances |
ANS: D
Nurses in the community are often assisted by informal helpers such as the significant others of the client, the landlord, the local police, clergy, and other concerned volunteers. Community-based nurses and clients have less contact with the traditional members of the interdisciplinary team than do individuals in the hospital-based setting.
DIF: Cognitive Level: Comprehension REF: Text Page: 88
TOP: Nursing Process: Assessment
MSC: NCLEX: Safe, Effective Care Environment;
19) The client assessment finding that deserves priority intervention by the nurse working in the community setting is that the client
| A. | receives Social Security disability income plus a small check from a trust fund. |
| B. | lives in an apartment with two clients who attend day hospital programs. |
| C. | has a sister who is interested and active in his care planning. |
| D. | purchases and uses marijuana on a frequent basis. |
ANS: D
Clients who regularly buy illegal substances often become medication noncompliant. Medication noncompliance, along with the disorganizing influence of illegal drugs on cellular brain function, promotes relapse. Options A, B, and C do not suggest problems.
DIF: Cognitive Level: Analysis REF: Text Page: 86, Text Page: 87
TOP: Nursing Process: Planning
MSC: NCLEX: Safe, Effective Care Environment;
20) A client tells the nurse at the medication management clinic that she hasn’t taken her antidepressant medication as the physician directed; she “forgets” the midday dose because she has lunch with friends and doesn’t want to be different because she takes pills. The most appropriate intervention for the nurse would be to
| A. | investigate the possibility of once-daily dosing. |
| B. | explain how taking each dose of medication on time relates to health maintenance. |
| C. | suggest she confide in a co-worker and ask if the co-worker would also take some sort of medication at noon. |
| D. | establish the nursing diagnosis of “noncompliance with medication regimen related to lack of knowledge” on the care plan. |
ANS: A
Option A has the highest potential for helping the client achieve compliance. Many antidepressants can be administered by once-daily dosing, a plan that increases compliance. Option B is reasonable but would not achieve the goal because it does not address the issue of stigma. Option C: The self-conscious client would not be comfortable doing this. Option D: A better etiology statement would be related to social stigma.
DIF: Cognitive Level: Analysis REF: Text Page: 89
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
21) The community psychiatric nurse makes the assessment that, based on biological signs, a seriously and persistently mentally ill client with a mood disorder seems to be somewhat more depressed than on his previous clinic visit a month ago. The client, however, states he feels the same. The intervention that gives credence to the nurse’s assessment while supporting client autonomy is to
| A. | arrange for a short hospitalization. |
| B. | schedule weekly clinic appointments. |
| C. | refer to the crisis intervention clinic. |
| D. | call the client’s family and ask them to observe the client closely. |
ANS: B
Scheduling clinic appointments at shorter intervals will give the opportunity for more frequent assessment of symptoms and allow the nurse to use early intervention. Option A is wasteful of scarce resources. Option C: If the client does not admit to having a crisis or problem this referral would be useless. Option D: This may or may not produce reliable information.
DIF: Cognitive Level: Analysis REF: Text Page: 89
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
22) A client with serious mental illness lives alone in a neighborhood in which she is well accepted as someone who can baby-sit for an hour or two or who will help with housekeeping chores if someone is ill. The client receives depot medication injections but lately has missed regular clinic appointments, saying “My life is so busy I couldn’t find time to come in.” To prevent hospitalization associated with noncompliance with medication regimen, the community mental health nurse should arrange for
| A. | psychosocial club membership. |
| B. | assertive community treatment. |
| C. | an appointment with a nurse in private practice. |
| D. | health maintenance organization authorization for changing to daily oral medication. |
ANS: B
The assertive community treatment team could bring the client’s medication to her in her neighborhood. Option D: Depot medication is a strategy to reduce noncompliance and is often preferable to daily oral medication. Options A and C do not directly relate to the noncompliance problem.
DIF: Cognitive Level: Application
REF: Text Page: 92, Text Page: 93, Text Page: 94
TOP: Nursing Process: Implementation
MSC: NCLEX: Safe, Effective Care Environment;
23) In a rush of words, a client tells the community mental health nurse “Everything’s a mess! I can’t concentrate. My disability check didn’t come. My roommate moved out and the rent is too much for me to pay on my own. To top it all off, my therapist is moving out of state. I don’t know where to turn and I feel as though I’m coming apart at the seams.” A nursing diagnosis the nurse should consider for this client is
| A. | decisional conflict related to challenges to personal values. |
| B. | spiritual distress related to ethical implications of treatment regimen. |
| C. | anxiety related to changes perceived as threatening to psychological equilibrium. |
| D. | deficient knowledge related to need to solve multiple problems affecting security needs. |
ANS: C
Subjective and objective data obtained by the nurse suggest the client is experiencing anxiety caused by multiple threats to security needs. Option A: Data are not present to suggest decisional conflict, ethical conflicts around treatment causing spiritual distress, or deficient knowledge.
DIF: Cognitive Level: Analysis REF: Text Page: 87, Text Page: 88
TOP: Nursing Process: Nursing Diagnosis
MSC: NCLEX: Psychosocial Integrity
24) The client that a nurse would plan to refer to a partial hospitalization program is the individual who
| A. | spent yesterday in the 24-hour supervised crisis care center and continues to be actively suicidal. |
| B. | has agoraphobia and panic episodes and needs psychoeducation for relaxation therapy. |
| C. | is well regulated on lithium and reports regularly for blood tests and clinic follow-up. |
| D. | is being discharged from an alcohol detoxification unit. He states, “I’m not sure I can abstain after my wife goes to work in the morning.” |
ANS: D
This client could profit from the structure and supervision provided by spending the day at the partial hospitalization program. During the evening, at night, and on weekends his wife could assume responsibility for supervision. Option A: This client would need hospitalization. Option B: This client could be referred to home care. Option C: This client could continue on the same plan.
DIF: Cognitive Level: Analysis REF: Text Page: 90
TOP: Nursing Process: Planning
MSC: NCLEX: Safe, Effective Care Environment;
25) For the client to be discharged from acute hospital care to clinical case management at home, care planning should be predicated on evidence that best outcomes will be produced by
| A. | weekly follow-up for 6 weeks, then every 2 weeks. |
| B. | monthly follow-up for 6 months to 1 year. |
| C. | no follow-up for 3 months, then quarterly visits. |
| D. | referral to the assertive treatment team for daily contact. |
ANS: A
Best outcomes are achieved when clients have regular, frequent follow-up in the community. Options B and C provide too little follow-up. Option D provides a more intensive follow-up than may be required.
DIF: Cognitive Level: Analysis REF: Text Page: 90
TOP: Nursing Process: Planning
MSC: NCLEX: Safe, Effective Care Environment;
OTHER
1) A nurse can best address factors of critical importance to successful community treatment during a new client interview by including assessments relative to (more than one answer may be correct)
- housing adequacy and stability.
- income adequacy and stability.
- family and other support systems.
- early psychosocial development.
- substance abuse history and current use.
ANS:
A, B, C, E
Rationale: Early psychosocial developmental history is less relevant to successful outcomes in the community than the assessments listed in the other options. If a client is homeless or fears homelessness, focusing on other treatment issues is impossible. Option B: Sufficient income for basic needs and medication is necessary. Option C: Adequate support is a requisite to community placement. Option D: This information has less bearing on the success of community treatment than the issues related to daily living arrangements. Option E: Substance abuse undermines medication effectiveness and interferes with community adjustment.
DIF: Cognitive Level: Application REF: Text Page: 87, Text Page: 88
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity
2) The client statements that identify aspects of nursing functions of high therapeutic value to a client being followed by an interdisciplinary community mental health team are “The nurse (more than one answer may be correct)
- talks in language I can understand.”
- looks at me as a whole person with lots of needs.”
- lets me do whatever I choose without interfering.”
- helps me keep track of my medication.”
- is willing to go on a date with me.”
ANS:
A, B, D
Rationale: Each of the correct answers is an example of appropriate nursing foci: communicating at a level understandable to the client, using holistic principles to guide care, and providing medication supervision. Option C suggests a laissez faire attitude on the part of the nurse, when the nurse should provide thoughtful feedback and help clients test alternative solutions. Option E is a boundary violation.
DIF: Cognitive Level: Analysis REF: Text Page: 88, Text Page: 89
TOP: Nursing Process: Implementation
MSC: NCLEX: Safe, Effective Care Environment;
Varcarolis: Foundations of Psychiatric Mental Health Nursing: A
Clinical Approach, 5th Edition
Test Bank
Chapter 9: Assessment Strategies and the Nursing Process
MULTIPLE CHOICE
1) A new graduate with an associate’s degree in nursing has just completed the new staff orientation to the psychiatric unit. The aspect of nursing care this nurse must have an advanced practice nurse perform is
| A. | performing a mental health assessment interview. |
| B. | establishing a therapeutic relationship. |
| C. | individualizing a nursing care plan. |
| D. | prescribing psychotropic medication. |
ANS: D
Prescriptive privileges are granted to masters-prepared nurse practitioners who have taken special courses on prescribing medication. The nurse prepared at the basic level is permitted to perform mental health assessments, establish relationships, and provide individualized care planning.
DIF: Cognitive Level: Application REF: Text Page: 149
TOP: Nursing Process: Implementation
MSC: NCLEX: Safe, Effective Care Environment;
2) Admission data for a newly admitted client who is severely depressed reveal he has lost 20 pounds over the past month, has chronic low self-esteem, and has both the intent and a plan for committing suicide. He has been taking a selective serotonin reuptake inhibitor for 1 week without remission of symptoms. The priority nursing diagnosis is
| A. | imbalanced nutrition: less than body requirements. |
| B. | chronic low self-esteem. |
| C. | risk for suicide. |
| D. | ineffective protection. |
ANS: C
Risk for suicide is the priority diagnosis when the client has both suicidal ideation and has developed a plan to carry out the suicidal intent. Imbalanced nutrition and chronic low self-esteem are viable nursing diagnoses, but these problems do not affect client safety as urgently as would a suicide attempt. Ineffective protection would be of greater concern if the client were taking risperidone or an immune suppressant drug.
DIF: Cognitive Level: Analysis REF: Text Page: 145
TOP: Nursing Process: Nursing Diagnosis
MSC: NCLEX: Safe, Effective Care Environment;
3) Admission data for a newly admitted client who is severely depressed reveal he has lost 20 pounds over the past month, has chronic low self-esteem, and has both the intent and a plan for committing suicide. He has been taking a selective serotonin reuptake inhibitor for 1 week without remission of symptoms. The nurse must plan interventions directed toward meeting the client outcome: Client will refrain from gestures and attempts at killing self. The nursing intervention most directly related to this outcome is
| A. | offer high-calorie fluids as between-meal nourishment. |
| B. | assist client to identify three personal strengths. |
| C. | observe client for therapeutic effects of psychotropic medication. |
| D. | implement suicide precautions. |
ANS: D
Option D is the only option related to client safety. Option A relates to nutrition. Option B relates to self-esteem. Option C relates to medication therapy.
DIF: Cognitive Level: Analysis
REF: Text Page: 146, Text Page: 147, Text Page: 148
TOP: Nursing Process: Planning
MSC: NCLEX: Safe, Effective Care Environment;
4) The client’s nursing diagnosis is disturbed sleep pattern related to anxiety. The desired outcome is that client will sleep for a minimum of 5 hours nightly by October 31. On November 1 review of sleep data for the 6 days of hospitalization shows the client sleeps an average of 4 hours nightly and takes a 2-hour afternoon nap. The outcome can be evaluated as
| A. | consistently demonstrated. |
| B. | often demonstrated. |
| C. | sometimes demonstrated. |
| D. | never demonstrated. |
ANS: D
Although the client is sleeping 6 hours daily, the total is not in one uninterrupted session at night. Therefore the outcome must be evaluated as never demonstrated.
DIF: Cognitive Level: Analysis REF: Text Page: 149
TOP: Nursing Process: Evaluation
MSC: NCLEX: Safe, Effective Care Environment;
5) The client’s nursing diagnosis is disturbed sleep pattern related to anxiety. The desired outcome is that the client will sleep for a minimum of 5 hours nightly by October 31. On November 1 sleep data show the client sleeps an average of 4 hours nightly and takes a 2-hour afternoon nap. After the evaluation, the nurse should
| A. | leave the care plan unchanged. |
| B. | remove the nursing diagnosis from the care plan. |
| C. | write a new nursing diagnosis that better reflects the problem and its cause. |
| D. | extend the time in which the goal is to be accomplished and examine interventions. |
ANS: D
Sleeping a total of 5 hours at night is still a reasonable outcome. Extending the time frame for attaining the outcome is appropriate. Examining interventions might result in planning an activity during the afternoon rather than permitting a nap. Option A is inappropriate. At the very least, the time in which the outcome is to be attained must be extended. Option B could be used when the outcome goal has been met and the problem resolved. Option C is inappropriate because no other nursing diagnosis relates to the problem.
DIF: Cognitive Level: Analysis REF: Text Page: 149
TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
6) The nurse interviewed a client who participated reluctantly, answering questions with minimal responses and rarely making eye contact with the nurse. When documenting the baseline data obtained during the interview the nurse should include
| A. | only data obtained from client verbal responses. |
| B. | a disclaimer that the client was uncooperative and provided minimal data. |
| C. | both the content derived from client subjective responses and a description of the client’s behavior during the interview. |
| D. | speculation regarding the reason the client was unwilling to respond openly during the interview. |
ANS: C
Both content and process of the interview should be documented. Option A provides a skewed picture of the client. Option B is subjectively worded. An objective description of client behavior would be preferable. Option D: Speculation is inappropriate.
DIF: Cognitive Level: Application REF: Text Page: 142
TOP: Nursing Process: Assessment
MSC: NCLEX: Safe, Effective Care Environment;
7) Before interviewing a new client, the nurse is told by another health care worker, “I know that client. He’s usually nutty as a fruitcake when he is admitted, and not much better when we discharge him.” The nurse’s responsibility is to
| A. | accept the other worker’s assessment as fact. |
| B. | form an impression based on the data he or she collects from all sources. |
| C. | validate the worker’s impression by contacting the family and other secondary sources. |
| D. | discuss the worker’s impression with the client during the course of the assessment interview. |
ANS: B
Assessment should include data obtained from both the primary and reliable secondary sources. Biased assessments by others should be evaluated as objectively as possible by the nurse, bearing in mind the possible effects of countertransference on others’ assessments.
DIF: Cognitive Level: Application REF: Text Page: 140, Text Page: 144
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity
8) While working with a client to establish outcomes for treatment, the nurse believes that an outcome suggested by the client is not in the client’s best interest. The best action for the nurse would be to
| A. | remain silent. |
| B. | tell the client that the outcome is not realistic. |
| C. | formulate a different, appropriate outcome for the client. |
| D. | explore the consequences that might occur if the outcome is achieved. |
ANS: D
The nurse should not impose outcomes on the client; however, the nurse has a responsibility to help the client evaluate what is in his or her best interests. Exploring possible consequences is an acceptable approach.
DIF: Cognitive Level: Application
REF: Text Page: 146, Text Page: 147, Text Page: 148
TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity
9) A client lists the following problems: “I have no sense of self-worth. I constantly think negative thoughts about myself. I feel anxious and shaky all the time. Sometimes my mood is so low that I think I want to go to sleep and never wake up.” The nursing interventions that should be accorded the highest priority relate to outcomes associated with
| A. | self-esteem. |
| B. | anxiety self-control. |
| C. | depression self-control. |
| D. | suicide self-restraint. |
ANS: D
The nurse would place a priority on monitoring and reinforcing suicide self-restraint because it relates directly and immediately to client safety. Client safety is always a priority concern. The nurse would also be expected to monitor and reinforce all client attempts to control anxiety, control depression, and develop self-esteem while giving priority attention to suicide self-restraint.
DIF: Cognitive Level: Analysis REF: Text Page: 148
TOP: Nursing Process: Planning
MSC: NCLEX: Safe, Effective Care Environment;
10) Select the best outcome for a client with the nursing diagnosis of impaired social interaction related to sociocultural dissonance, as evidenced by client stating “Although I’d like to, I don’t join in because I don’t speak the language so good.” Client will
| A. | cooperate with others. |
| B. | become more independent. |
| C. | express a desire to interact with others. |
| D. | consistently participate in unit group activity of his choice. |
ANS: D
The outcome describes social involvement on the part of the client. Neither cooperation nor independence has been an issue. The client has already expressed a desire to interact with others.
DIF: Cognitive Level: Analysis REF: Text Page: 146
TOP: Nursing Process: Planning (Outcome Identification)
MSC: NCLEX: Psychosocial Integrity
11) Nursing behaviors associated with the implementation phase of the nursing process are concerned with
| A. | gathering accurate and sufficient client-centered data. |
| B. | participating in mutual identification of client outcomes. |
| C. | carrying out interventions and coordinating care. |
| D. | comparing client responses and expected outcomes. |
ANS: C
Nursing behaviors relating to implementation include considering available resources, performing care-giving interventions, finding alternatives when necessary, and coordinating care with other team members.
DIF: Cognitive Level: Comprehension REF: Text Page: 148
TOP: Nursing Process: Implementation
MSC: NCLEX: Safe, Effective Care Environment;
12) Which statement made by a client during the initial assessment interview will provide the nurse with the best understanding of the client’s current problem and reason for seeking treatment?
| A. | “I can always trust my wife.” |
| B. | “You never know who will turn against you.” |
| C. | “I’ve been hearing the voices of my dead parents.” |
| D. | “I wish I knew what I’ve done to deserve such bad luck.” |
ANS: C
Option C tells the nurse that the client is experiencing auditory hallucinations.
The other statements are vague and do not clearly identify the client’s chief symptom.
DIF: Cognitive Level: Analysis
REF: Text Page: 140, Text Page: 141, Text Page: 142, Text Page: 143
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity
13) Which entry in the medical record will meet the requirement that the nurse must document with problem-oriented charting?
| A. | “A: Client muttering to self as though answering an unseen person. P: Sensory perceptual alteration related to internal auditory stimulation. I: Client received prn fluphenazine po at 9 AM and went to room to lie down. E: Client calmer by 9:30 AM. Returned to community room to watch TV.” |
| B. | “Agitated behavior. D: Client muttering to self as though answering an unseen person. A: Given Haldol 2 mg po and went to room to lie down. E: Client calmer. Returned to lounge to watch TV.” |
| C. | “S: Client states ‘I feel like I’m ready to blow up.’ O: Pacing hall and mumbling to self as though answering an unseen person. A: Client is experiencing auditory hallucinations. P: Offered prn Haldol 2 mg po. I: 2 mg Haldol po administered. E: Client calmer. Returned to lounge and watched TV.” |
| D. | “Client seen pacing hall and muttering to self as though answering an unseen person. Haldol 2 mg po administered at 9 AM with calming effect in 30 minutes. Stated he was no longer ‘bothered by the voices.’” |
ANS: C
Problem-oriented documentation uses the first letter of key words to organize data: S for subjective data, O for objective data, A for assessment, P for plan, I for intervention, and E for evaluation. Option A is an example of PIE charting. Option B is an example of focus documentation. Option D is an example of narrative documentation.
DIF: Cognitive Level: Analysis REF: Text Page: 150, Text Page: 151
TOP: Nursing Process: Implementation
MSC: NCLEX: Safe, Effective Care Environment;
14) A nurse is assigned to perform the assessment interview for a 65-year-old woman brought to the hospital emergency department by her 16-year-old granddaughter, who found her wandering around the yard of her suburban home, saying “I can’t find my way home.” The nurse finds the client to be so profoundly confused that she is unable to respond to or answer any questions posed. In this case the nurse should
| A. | persevere and record the client’s answers to questions on the agency assessment form. |
| B. | document the client’s confusion and obtain as much data as possible from the granddaughter. |
| C. | ask a more experienced nurse to perform the interview. |
| D. | call for a mental health advocate to support the client’s rights. |
ANS: B
When the client (primary source) is unable to provide information, secondary sources should be used, in this case the granddaughter. Later, more data may be obtained from other relatives or neighbors who are familiar with the client. Option C: An experienced nurse would probably do no better. Option D is unnecessary.
DIF: Cognitive Level: Application REF: Text Page: 144
TOP: Nursing Process: Assessment
MSC: NCLEX: Safe, Effective Care Environment;
15) A nurse is assigned to perform the assessment interview for a 65-year-old woman brought to the hospital emergency department by her 16-year-old granddaughter, who found her wandering around the yard of her suburban home, saying “I can’t find my way home.” The nurse finds the client to be so confused that she is unable to respond to or answer any questions posed. The nurse experiences feelings of profound sadness and reflects “She is like my grandmother: helpless.” The feelings being experienced by the nurse can be assessed as
| A. | autodiagnosis. |
| B. | countertransference. |
| C. | catastrophic reaction. |
| D. | defensive coping reaction. |
ANS: B
Countertransference is the nurse’s transference or response to a client that is based on the nurse’s unconscious needs, conflicts, problems, or view of the world. Option A: Autodiagnosis refers to the nurse’s self-monitoring and awareness of his or her own reactions. Option C: A catastrophic reaction refers to an angry, sometimes violent reaction by a client with dementia. Option D: The nurse is responding honestly rather than coping defensively.
DIF: Cognitive Level: Application REF: Text Page: 140
TOP: Nursing Process: Assessment
MSC: NCLEX: Safe, Effective Care Environment;
16) During the initial assessment interview the client becomes anxious and evasive when the nurse asks her if she has ever heard voices when no one else was around. The client asks, “What do you need to know that for?” The nurse should say
| A. | “Please be honest about this,” after repeating the question. |
| B. | “Sometimes questions seem highly personal, but we have our reasons for asking each one.” |
| C. | “What purpose do you think we might have in asking about whether you hear voices?” |
| D. | “I can see this subject makes you uncomfortable. We can discuss it at another time.” |
ANS: D
The nurse should not try to pry information out of a client who is reluctant to give the information. The nurse should note the client’s reaction to the question and carefully observe for behavioral signs that the client may be experiencing auditory hallucinations. Option A implies the client has been dishonest. Option B treats the client in a demeaning fashion. Option C is game playing.
DIF: Cognitive Level: Application REF: Text Page: 140
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
17) A 16-year-old client asks the nurse conducting the assessment interview “Why should I tell you anything? You’ll just run back and tell my mother whatever you find out.” The best reply for the nurse would be
| A. | “That’s not true. Whatever you tell me will be held in the strictest confidence.” |
| B. | “Your mother may find out what you say, but is that really such a bad thing?” |
| C. | “Anything you say about feelings is confidential, but things like suicidal thinking must be reported to the treatment team.” |
| D. | “It sounds as though you’re not really ready to work on your problems and make changes.” |
ANS: C
The client has a right to know that most information will be held in confidence but that certain material must be reported or shared with the treatment team, such as threats of suicide, homicide, use of illegal drugs, or issues of abuse. Option A is not strictly true. Option B will not inspire the confidence of the client. Option D is confrontational.
DIF: Cognitive Level: Application REF: Text Page: 150, Text Page: 151
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
18) The nurse interviewing an adolescent client should plan to use the HEADSSS interview topics to
| A. | establish rapport. |
| B. | identify risk factors. |
| C. | identify treatment objectives. |
| D. | assess level of current cognitive functioning. |
ANS: B
HEADSSS structures the interview to gather data useful in assessing risk factors. HEADSSS refers to home environment; education; activities; drug, alcohol, tobacco use; sexuality; suicide risk; and savagery (violence/abuse in the environment). Option A: Rapport would be difficult to establish if only the HEADSSS interview is used. Option C: Direct questions might better identify treatment objectives. Option D: The mental status examination would be preferable.
DIF: Cognitive Level: Comprehension REF: Text Page: 140, Text Page: 141
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity
19) When the nurse begins the assessment interview with a client, aged 62 years, she notes that the client gives answers to questions that seem somewhat vague or slightly unrelated to the question. The client also leans forward and frowns as she listens intently to the nurse. An appropriate question for the nurse to ask would be
| A. | “I notice you frowning. Are you feeling annoyed with me?” |
| B. | “Are you able to hear clearly when I speak in this tone of voice?” |
| C. | “How can I make this interview a bit easier for you?” |
| D. | “You seem to be having some trouble focusing on what I’m saying. Is something distracting you?” |
ANS: B
The client’s behaviors indicate she may have difficulty hearing. Identifying any physical need the client may have at the onset of the interview and making accommodations are important considerations. Option A: The nurse is jumping to conclusions. Option C may not elicit a concrete answer. Option D is a way of asking about the presence of auditory hallucinations, which is not appropriate because the nurse has observed that the client seems to be listening intently to her.
DIF: Cognitive Level: Application REF: Text Page: 140
TOP: Nursing Process: Implementation
MSC: NCLEX: Safe, Effective Care Environment;
20) A nurse is reluctant to ask questions related to spiritual matters during client interviews. At what point in the interview could the nurse logically ask the question “Does your faith help you in stressful situations?” During the assessment of
| A. | substance use and abuse. |
| B. | childhood growth and development. |
| C. | usual client coping strategies. |
| D. | self-assessment of strengths and weaknesses. |
ANS: C
When discussing coping strategies the nurse might ask what the client does when he or she becomes upset, what usually relieves stress, and to whom the client goes to talk about problems. The question regarding whether the client’s faith helps deal with stress fits well here. It would seem out of place if introduced during exploration of the other topics.
DIF: Cognitive Level: Application
REF: Text Page: 142, Text Page: 143, Text Page: 144
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity
21) When a new client has been admitted to the unit, the nurse takes the client on a tour, tells the client about the rules of the unit that guide behavior and activities of daily living, and discusses the daily schedule. In doing this the nurse is engaged in
| A. | counseling. |
| B. | health teaching. |
| C. | milieu management. |
| D. | psychobiological intervention. |
ANS: C
Milieu management provides a therapeutic environment in which the client can feel comfortable and safe, while engaging in activities that meet the client’s physical and mental health needs. Option A: Counseling refers to activities designed to promote problem solving and enhanced coping and includes interviewing, crisis intervention, stress management, and conflict resolution. Option B: Health teaching involves identifying health education needs and giving information about these needs. Option D: Psychobiological interventions involve medication administration and monitoring response to medications.
DIF: Cognitive Level: Comprehension REF: Text Page: 148
TOP: Nursing Process: Implementation
MSC: NCLEX: Safe, Effective Care Environment;
OTHER
1) The nurse notes the following entry on the client’s plan of care: “Outcome: Client will demonstrate suicide self-control. Interventions: Initiate suicide precautions. Allow client to retain personal belongings. Allow client to leave unit unsupervised.” Which principles of planning a nursing intervention to facilitate achievement of identified client outcomes are violated? (More than one answer may be correct.)
- Feasibility
- Evidence basis
- Appropriateness
- Within the capability of the nurse
ANS:
B, C
Rationale: All interventions are not supported by evidence. Evidence supports removing personal property that can be used to attempt self-harm. Evidence also supports restricting the client to the unit and closely supervising client activity while on the psychiatric unit. If the client leaves the unit, staff would accompany the client on a one-to-one basis. The interventions are inappropriate because they do not provide a safe environment for the client. Option A: The interventions are feasible although misguided. Option D: The interventions are within the capability of the nurse, but a nurse using good judgment would question them.
DIF: Cognitive Level: Analysis
REF: Text Page: 146, Text Page: 147, Text Page: 148
TOP: Nursing Process: Planning
MSC: NCLEX: Safe, Effective Care Environment;
2) The nurse performing the assessment interview for a client decides to have the client use the Zung Self-Report Inventory at the end of the interview. The functions accomplished with this tool include (more than one answer may be correct)
- identifying North American Nursing Diagnosis Association nursing diagnoses.
- obtaining data related to current symptoms of depression.
- establishing a baseline for evaluation of progress over time.
- comparing client responses with responses of others with depression.
ANS:
B, C, D
Rationale: A self-report rating scale is useful for obtaining data about the client’s perception of illness at the beginning of treatment, and, with repeated administration, to provide information about progress over time. The data obtained also permit comparison for research purposes of client responses with those of groups of people with the same illness. This scale does not refer directly to nursing diagnoses, although data gathered may indirectly assist the nurse in formulating nursing diagnoses.
DIF: Cognitive Level: Application REF: Text Page: 144, Text Page: 145
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity
3) After a nurse has completed the assessment for a new client with a psychiatric disorder, data are analyzed to formulate nursing diagnoses. The information that will be conveyed by the nursing diagnoses includes (more than one answer may be correct)
- medical judgments about the disorder.
- unmet client needs present at the moment.
- supporting data that validate the diagnoses.
- probable causes that will be targets for nursing interventions.
ANS:
B, C, D
Rationale: Nursing diagnoses focus on phenomena of concern to nurses rather than on medical diagnoses.
DIF: Cognitive Level: Application REF: Text Page: 145
TOP: Nursing Process: Nursing Diagnosis
MSC: NCLEX: Psychosocial Integrity
4) Which strategies would be helpful for the nurse to use when gathering assessment data about a client whose family has indicated that he is very suspicious and believes the FBI has him under surveillance? (More than one answer may be correct.)
- Ask the client to identify the problem as he sees it.
- Seek information about when the problem began.
- Listen to the client’s theory about the cause of the problem.
- Tell the client his ideas are not realistic.
- Reassure the client of his safety.
- Tell the client that staff will control his behavior
ANS:
A, B, C, E
Rationale: During the assessment interview the nurse should listen attentively and accept the client’s statements in a nonjudgmental way. Because the client is suspicious and fearful, reassuring him of his safety may be helpful, although he is unlikely to trust the nurse so early in the relationship. Option D suggests to the client that the nurse is not willing to try to understand his views. Option F may be perceived as a threat.
DIF: Cognitive Level: Application
REF: Text Page: 140, Text Page: 141, Text Page: 142, Text Page: 143
TOP: Nursing Process: Assessment
MSC: NCLEX: Safe, Effective Care Environment;
Varcarolis: Foundations of Psychiatric Mental Health Nursing: A
Clinical Approach, 5th Edition
Test Bank
Chapter 11: The Clinical Interview and Communication Skills
MULTIPLE CHOICE
1) As a client converses with the nurse, she states “I dreamed I was stoned. When I woke up, I was feeling emotionally drained, as though I hadn’t rested well.” If the nurse needs clarification of “stoned,” it would be appropriate to say
| A. | “It sounds as though you were quite uncomfortable with the content of your dream.” |
| B. | “Can you give me an example of what you mean by stoned?” |
| C. | “I understand what you’re saying. Bad dreams leave me feeling tired, too.” |
| D. | “So, all in all, you feel as though you had a rather poor night’s sleep?” |
ANS: B
The technique of exploring is useful because it helps the nurse examine meaning. Option 2 directly asks for clarification. Option A focuses on client feelings. Options C and D fail to clarify the meaning of the word in question.
DIF: Cognitive Level: Application REF: Text Page: 189
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
2) At the beginning of a clinical interview the nurse tells a teenaged client “While I’m here with you I will focus on the content and process of our communication as a participant observer.” The client looks blankly at the nurse. The nurse can make the assessment that communication was not understood because of
| A. | a personal factor: the use of terms not understood by the client. |
| B. | a social factor: the socioeconomic difference between nurse and client. |
| C. | an environmental factor: lack of privacy. |
| D. | incongruent verbal and nonverbal communication. |
ANS: A
Various personal, environmental, and social factors may be responsible for ineffective communication. In this case, a personal factor is involved. The nurse used a highly technical explanation of his purpose for talking with the client. Data are not present in the scenario to support the choice of any other option.
DIF: Cognitive Level: Application REF: Text Page: 178
TOP: Nursing Process: Evaluation MSC: NCLEX: Psychosocial Integrity
3) The client remarks “My husband and I get along just fine. We usually agree on everything.” As the client speaks her foot is moving continuously and she twirls a button on her blouse. What assessment can the nurse make? The client’s communication is
| A. | clear. |
| B. | explicit. |
| C. | inadequate. |
| D. | mixed. |
ANS: D
Mixed messages involve the transmission of conflicting or incongruent messages by the speaker. The client’s verbal message that all was well in the relationship was modified by the nonverbal behaviors denoting anxiety. Data are not present to support the choice of the verbal message being clear, explicit, or inadequate.
DIF: Cognitive Level: Application REF: Text Page: 180, Text Page: 181
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity
4) During the first interview with a restless young man, the nurse notices that he does not make eye contact throughout most of the interview. The nurse can correctly assume that
| A. | he is not to be trusted in what he says because he is evasive. |
| B. | he is feeling sad and cannot look the nurse in the eye. |
| C. | he is shy and the nurse must move slowly. |
| D. | more information is needed to draw a conclusion. |
ANS: D
The data presented are insufficient to draw a conclusion. The nurse must continue to gather information.
DIF: Cognitive Level: Application REF: Text Page: 181, Text Page: 184
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity
5) Which statement made by a nurse during a nurse-client interaction may underrate a client’s feelings and belittle his or her concerns?
| A. | “You appear tense.” |
| B. | “Everything will be all right.” |
| C. | “I notice you are biting your lip.” |
| D. | “I’m not sure I follow you.” |
ANS: B
Option B offers false reassurance. This is a nontherapeutic technique that suggests to a client that his or her views and feelings are not being taken seriously. Options A, C, and D use therapeutic techniques.
DIF: Cognitive Level: Analysis REF: Text Page: 191, Text Page: 192
TOP: Nursing Process: Evaluation MSC: NCLEX: Psychosocial Integrity
6) The nurse is talking with a young male client and has 5 minutes to go in the session with him. He has been silent and sullen most of the session and has been staring at the floor for the last 10 minutes. A troubled young woman comes to the door of the room and says to the nurse, “I really need to talk to you.” The nurse should
| A. | tell the woman she is busy at the present time. |
| B. | end the session and spend time with the young woman. |
| C. | invite the woman to sit down and join in the session with the other client. |
| D. | tell the woman that the session with this client will take 5 more minutes, after which the nurse will talk with her. |
ANS: D
When a specific duration for sessions has been set, the nurse must adhere to the schedule. Leaving the first client would be equivalent to abandonment and would destroy any trust the client had in the nurse. Adhering to the contract demonstrates that the nurse can be trusted and that the client and the sessions are viewed as important. Option A preserves the nurse-client relationship with the young male client but may seem abrupt to the young female client. Option B abandons the young male client. Option C does not observe the contract with the young male client.
DIF: Cognitive Level: Application REF: Text Page: 177
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
7) Which remark by the nurse would be an appropriate way to begin a clinical interview session?
| A. | “How shall we start today?” |
| B. | “Shall we talk about losing your privileges yesterday?” |
| C. | “What happened when your husband came to visit yesterday?” |
| D. | “Let’s get started trying to unravel your marital relationship.” |
ANS: A
The interview is client centered; thus the issues are chosen by the client. The nurse assists the client by using communication skills and actively listening to provide opportunities for the client to reach goals. In options B, C, and D the nurse selects the topic.
DIF: Cognitive Level: Application REF: Text Page: 173
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
8) The nurse can best communicate to the client that she or he is interested in listening by
| A. | restating the feeling or thought the client has expressed. |
| B. | making a judgment about the client’s problem. |
| C. | asking a direct question, such as “Did you feel angry?” |
| D. | saying “I understand what you’re saying.” |
ANS: A
Restating allows the client to validate the nurse’s understanding of what has been communicated. Restating is an active listening technique. Option B: Judgments should be suspended in a nurse-client relationship. Option C: Closed-ended questions ask for specific information rather than showing understanding. Option D states that the nurse understands, but the client has no way of measuring the understanding.
DIF: Cognitive Level: Application REF: Text Page: 189
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
9) The client has disclosed several of his concerns and associated feelings. If the nurse wishes to seek clarification he could say
| A. | “What are the common elements here?” |
| B. | “Tell me again.” |
| C. | “Am I correct in concluding that . . .” |
| D. | “Tell me everything from the beginning.” |
ANS: C
Option C permits clarification to ensure that both the nurse and client share mutual understanding of the communication. Option A is a closed-ended question. Options B and D are implied questions.
DIF: Cognitive Level: Application REF: Text Page: 189, Text Page: 190
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
10) A client tells the nurse “I don’t think I’ll ever get out of here.” A therapeutic response would be
| A. | “You shouldn’t talk that way. Of course you’ll leave here!” |
| B. | “Everyone feels that way sometimes.” |
| C. | “You don’t think you’re making progress?” |
| D. | “Keep up the good work and you certainly will.” |
ANS: C
In option C the nurse is reflecting by putting into words what the client is hinting. By making communication more explicit, issues are easier to identify and resolve. Options A, B, and D are nontherapeutic techniques. Option A is disapproving. Option B minimizes feelings. Option D is falsely reassuring.
DIF: Cognitive Level: Application REF: Text Page: 191, Text Page: 192
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
11) Documentation in a client’s chart includes the following information: “Throughout a 5-minute interaction the client fidgeted and tapped his left foot, periodically covered his face with his hands, looked under his chair, all while stating he was enjoying spending time with this nurse.” Of the following assessments, which is most accurate?
| A. | The client is giving positive feedback about the nurse’s communication techniques. |
| B. | The nurse is viewing the client’s behavior through a cultural filter. |
| C. | The client’s verbal and nonverbal messages are incongruent. |
| D. | The client is demonstrating psychotic behaviors. |
ANS: C
When a verbal message is not reinforced with nonverbal behavior, the message is confusing and incongruent. Some clinicians call it a “mixed message.” Option A is an inaccurate statement. Option B: A cultural filter determines what we will pay attention to and what we will ignore. This concept is not relevant to the situation presented. Option D: Data are insufficient to draw this conclusion.
DIF: Cognitive Level: Application REF: Text Page: 180, Text Page: 181
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity
12) The nurse finds himself feeling angry with a client. The nurse should
| A. | tell the nurse manager to assign the client to another nurse. |
| B. | suppress the angry feelings. |
| C. | express the anger openly. |
| D. | discuss the anger with a clinician during a supervision session. |
ANS: D
The nurse is accountable for the relationship. Objectivity is threatened by strong positive or negative feelings toward a client. Supervision is necessary to work through negative feelings. Option A: This is not a first-line solution. Option B: Suppression rarely results in a satisfactory outcome for client or nurse. Option C: Open expression of anger will confuse a client who has been unaware of the nurse’s feelings.
DIF: Cognitive Level: Application
REF: Text Page: 173, Text Page: 174, Text Page: 175
TOP: Nursing Process: Implementation
MSC: NCLEX: Safe, Effective Care Environment;
13) As she talks with a deeply depressed client, the nurse notices that the client is unable to maintain eye contact. The client drops her chin to her chest and looks down. The nurse has made an assessment of the client’s
| A. | nonverbal communication. |
| B. | mental status. |
| C. | nursing diagnosis. |
| D. | social skill. |
ANS: A
Eye contact and body movements are considered nonverbal communication.
DIF: Cognitive Level: Application REF: Text Page: 180
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity
14) During a therapy session a client cries as the nurse explores the relationship of the client and her now-deceased mother. The client sobs “I shouldn’t be blubbering like this.” A response by the nurse that will hinder communication is
| A. | “The relationship with your mother is very painful for you.” |
| B. | “I can see that you feel sad about this situation.” |
| C. | “Why do you think you are so upset?” |
| D. | “Crying is a way of expressing the hurt you’re experiencing.” |
ANS: C
“Why” questions often imply criticism or seem intrusive or judgmental. They are difficult to answer; thus they are barriers to communication. The other options are therapeutic in nature.
DIF: Cognitive Level: Application REF: Text Page: 193
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
15) During the first interview with a woman who has just lost her son in a car accident, the nurse feels so sorry for the woman that she reaches out and touches her. The nurse’s response
| A. | is empathetic and will encourage the woman to continue to express her feelings. |
| B. | will be perceived by the client as intrusive and overstepping boundaries. |
| C. | is inappropriate because a “no touch” rule should be applied to all psychiatric clients. |
| D. | may be premature as the cultural and individual interpretation of touch is unknown. |
ANS: D
Touch has various cultural and individual interpretations. Nurses should refrain from using touch until an assessment can be made regarding the way in which the client will perceive touch. The other options present prematurely drawn conclusions.
DIF: Cognitive Level: Application REF: Text Page: 184
TOP: Nursing Process: Evaluation MSC: NCLEX: Psychosocial Integrity
16) The nurse working with a young woman who is depressed tries to cheer the client by being casual and humorous. At one point the client smiles. What assessment can be made?
| A. | The nurse has succeeded in reaching the client and is on the way to cheering her. |
| B. | The use of distraction and humor can be added to the intervention list in the plan of care. |
| C. | The nurse has identified an approach that may prove useful in other, similar situations. |
| D. | The nurse needs to seek supervision because the approach described is not acceptable. |
ANS: D
Clinical supervision will review the nurse’s actions and thoughts and help the nurse arrive at a more therapeutic approach. Attempts at cheering up a depressed client serve only to emphasize the disparity between the client’s mood and that of others. Active listening should be the technique used by the nurse. Options A, B, and C suggest the approach is therapeutic when it is not.
DIF: Cognitive Level: Application
REF: Text Page: 186, Text Page: 187, Text Page: 188
TOP: Nursing Process: Evaluation MSC: NCLEX: Psychosocial Integrity
17) A male African American client says to a white male nurse “There’s no sense in talking with you. You wouldn’t understand because you live in a white world.” The best response for the nurse would be to
| A. | explain that the nurse can understand because everyone goes through the same experiences. |
| B. | ask the client to give an example of something he thinks the nurse wouldn’t understand. |
| C. | reassure him that nurses are trained to deal with people from all cultures. |
| D. | gently change the subject to one that is less emotionally charged. |
ANS: B
Having the client speak in specifics rather than globally will help the nurse understand the client’s perspective. This approach will help the nurse draw out the client.
DIF: Cognitive Level: Application REF: Text Page: 189
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
18) A nurse working with a Filipino American client has noted that the client rarely makes eye contact during their interactions. The nurse hypothesizes that the reason for lack of eye contact is client low self-esteem and plans interventions designed to raise the client’s self-esteem. After 3 weeks the client’s eye contact has not improved. The nurse’s clinical supervisor suggests that a problem exists with the assessment and plan. The most accurate formulation of the problem is
| A. | the client’s poor eye contact is indicative of anger and hostility that are going unaddressed. |
| B. | the client’s eye contact should have been directly addressed by role playing to increase comfort with eye contact. |
| C. | the nurse should have considered the client’s culture during the assessment and before making a plan. |
| D. | the nurse should not have independently embarked on assessment and planning. |
ANS: C
The amount of eye contact a person engages in is often culturally determined. In some cultures eye contact is considered insolent, whereas in others eye contact is expected. Filipino Americans often prefer not to engage in direct eye contact.
DIF: Cognitive Level: Analysis REF: Text Page: 184
TOP: Nursing Process: Evaluation MSC: NCLEX: Psychosocial Integrity
19) When a Mexican American client and the primary nurse are sitting together, the client often takes the nurse’s hand and holds it. The client also takes the nurse’s hand or links her arm through the nurse’s when they are walking. The nurse has made the assessment that the client is a lesbian and is quite uncomfortable with the behavior. Which of the following alternatives might be a more accurate assessment?
| A. | The client is accustomed to touch during conversation, as are members of many Hispanic subcultures. |
| B. | The client understands that touch makes the nurse uncomfortable and controls the relationship based on that factor. |
| C. | The client is afraid of being alone. When touching the nurse, the client is reassured that she is not alone. |
| D. | The nurse is homophobic. |
ANS: A
The most likely answer is that the client’s behavior is culturally influenced. Hispanic women frequently touch women they consider to be their friends. Although the other options are possible, they are much less likely.
DIF: Cognitive Level: Application REF: Text Page: 184
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity
20) A Puerto Rican American client uses dramatic body language whenever describing emotional discomfort. Of the possibilities below, which is most likely to be an accurate explanation of the client’s behavior? The client
| A. | wishes to impress staff with her degree of emotional pain. |
| B. | has a histrionic character disorder and uses this behavior habitually. |
| C. | believes dramatic body language has high sexual appeal. |
| D. | is a member of a culture in which dramatic body language is the norm. |
ANS: D
Members of Hispanic American subcultures tend to use high affect and dramatic body language as they communicate. The other options are more remote possibilities.
DIF: Cognitive Level: Application REF: Text Page: 183, Text Page: 184
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity
21) What would be the preferable remark for a student nurse to use after introductions have been made to begin the first nurse-client interview?
| A. | “So tell me, do you like having students here?” |
| B. | “I’d like to have you tell me your problems.” |
| C. | “Perhaps you would like to begin by telling me about some of the stresses you’ve experienced recently.” |
| D. | “I read your chart and understand that you would like to focus on new ways to improve your self-esteem.” |
ANS: C
The nurse-client interview should be client centered and client paced. Option C is the least directive approach and turns the interview over to the client. Option A is student focused. Option B is a demand for immediate information. Option D takes the pacing of the interview away from the client.
DIF: Cognitive Level: Application REF: Text Page: 173
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
22) During a nurse-client interview the client attempts to shift the session focus from himself to the nurse by asking personal questions. The nurse should respond by saying
| A. | “You have no right to ask questions about my personal life.” |
| B. | “Nurses prefer to direct the interview.” |
| C. | “You’ve turned the tables on me.” |
| D. | “This time we spend together is for you to discuss your concerns.” |
ANS: D
When a client chooses to focus on the nurse, the nurse should refocus the discussion back onto the client. Option D refocuses discussion in a neutral way. Option A shows indignation. Option B reflects superiority. Option C states the fact but does not refocus the interview.
DIF: Cognitive Level: Application REF: Text Page: 177
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
23) The nurse interviewing a client who is having difficulty staying focused could best help the client by saying
| A. | “Go on.” |
| B. | “What would you like to discuss?” |
| C. | “Tell me what is happening right now.” |
| D. | “It seems as though you are having trouble staying focused.” |
ANS: C
Closed-ended questions may be necessary to elicit information from a client who is having difficulty concentrating.
DIF: Cognitive Level: Application REF: Text Page: 190
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
24) The nurse records the following data about a client: “Client has not spoken despite repeated efforts to elicit speech by nurse and other staff. Makes no eye contact and is inattentive to staff who attempt to engage him, gazing off to the side or looking upward rather than at speaker.” A possible nursing diagnosis that deserves more investigation is
| A. | defensive coping. |
| B. | risk for violence. |
| C. | decisional conflict. |
| D. | impaired verbal communication. |
ANS: D
The defining characteristics are more related to the nursing diagnosis of impaired verbal communication than to the other nursing diagnoses.
DIF: Cognitive Level: Analysis REF: Text Page: 179
TOP: Nursing Process: Nursing Diagnosis
MSC: NCLEX: Psychosocial Integrity
25) The remark by the nurse that gives the client verbal tracking feedback is
| A. | “Describe your relationship with your wife.” |
| B. | “Am I correct in stating you are feeling angry with your wife?” |
| C. | “You’re saying you do not have a good relationship with your wife.” |
| D. | “Give me an example of not getting along with your wife.” |
ANS: C
Verbal tracking simply keeps track of what the client is saying. It is giving neutral feedback in the form of restating or summarizing what the client has said. Option B seeks validation. Options A and D are examples of exploring.
DIF: Cognitive Level: Application REF: Text Page: 183
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
26) A principle that should guide the nurse in determining the extent of silence to allow during client interview sessions is that
| A. | the nurse is responsible for breaking silences. |
| B. | clients withdraw if silences are prolonged. |
| C. | silence provides meaningful moments for reflection. |
| D. | silence helps clients know that what they said was understood. |
ANS: C
Silence can be helpful to both participants by giving each an opportunity to contemplate what has transpired, weigh alternatives, and formulate ideas. Option A is not a principle related to silences. Options B and D are not true statements. Feedback helps clients know they have been understood.
DIF: Cognitive Level: Analysis REF: Text Page: 185, Text Page: 186
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
27) During a session with a client who seems bewildered by his predicament, the nurse is conflicted about whether to provide advice. The rule of thumb that should be followed is that giving advice to a client
| A. | is rarely helpful. |
| B. | fosters independence. |
| C. | lifts the burden of personal decision making. |
| D. | helps the client develop feelings of personal adequacy. |
ANS: A
Giving advice fosters dependence on the nurse and interferes with the client’s right to make personal decisions. It robs clients of the opportunity to weigh alternatives and develop problem-solving skills. Furthermore, it contributes to client feelings of personal inadequacy. It also keeps the nurse in control and feeling powerful.
DIF: Cognitive Level: Comprehension REF: Text Page: 192, Text Page: 193
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
28) The relationship between a nurse and a client as it relates to status and power is best described by the term
| A. | symmetrical. |
| B. | complementary. |
| C. | incongruent. |
| D. | paralinguistic. |
ANS: B
When a difference in power exists, as between a student and teacher or nurse and client, the relationship is said to be complementary. Symmetrical relationships exist between individuals of like or equal status. Incongruent and paralinguistic are not terms used to describe relationships.
DIF: Cognitive Level: Comprehension REF: Text Page: 178
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity
29) A client seeks to elicit personal information about the nurse by asking several direct questions about the nurse’s living arrangements. To refocus the interview the nurse should say
| A. | “I am uncomfortable when you ask me personal questions, so please stop.” |
| B. | “It seems a bit odd that you are focusing on me rather than on yourself.” |
| C. | “Your questioning is manipulative and distracting us from our purpose.” |
| D. | “This is your time to focus on your situation. Tell me about your concerns.” |
ANS: D
Option D restates the purpose of the interview, shifting the focus off the nurse and back to the client while remaining neutral. Option A remains nurse focused. Option B challenges the client. Option C is accusatory.
DIF: Cognitive Level: Application REF: Text Page: 177
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
OTHER
1) A new nurse tells a mentor “I want to convey to my clients that I am interested in them and that I want to listen to what they have to say.” The behaviors helpful in meeting the nurse’s goal include the nurse (more than one answer may be correct)
- sitting behind a desk, facing the client.
- introducing herself to the client and identifying her staff role.
- using facial expressions that convey interest and encouragement.
- assuming an open body posture and sometimes mirror imaging.
- maintaining control of the topic under discussion by asking direct questions.
ANS:
B, C, D
Rationale: Options B, C, and D are helpful behaviors. Trust is fostered when the nurse introduces herself and identifies her role. Facial expressions that convey interest and encouragement support the nurse’s verbal statements to that effect and strengthen the message. An open body posture conveys openness to listening to what the client has to say. Mirror imaging enhances client comfort. Option A: The desk places a physical barrier between the nurse and client. A face-to-face stance should be avoided when possible and a less intense 90- or 120-degree angle used to permit either party to look away without discomfort. Option E: Once introductions have been accomplished the nurse should turn the interview over to the client by using an open-ended question such as “Where should we start?”
DIF: Cognitive Level: Application REF: Text Page: 172, Text Page: 173
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
