Foundations of Psychiatric Mental Health Nursing A Clinical Approach, 5th Edition by Elizabeth M. Varcarolis – Test Bank

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Varcarolis: Foundations of Psychiatric Mental Health Nursing: A 

Clinical Approach, 5^th Edition

Test Bank

Chapter 5: Mental Health Nursing in Acute Care Settings 

MULTIPLE CHOICE

1)The nurse manager has the task of introducing staff to the use of clinical pathways. The nurse manager will need to explain that clinical pathways are used in managed care settings to

A.	identify obstacles to effective care.
B.	stabilize aggressive clients.
C.	relieve nurses of planning responsibilities.
D.	streamline the care process and save money.

ANS: D

Clinical pathways provide guidelines for assessments, interventions, treatments, and outcomes as well as a designated timeline for accomplishment. Deviations from the timeline must be reported and investigated. Clinical pathways streamline the care process and save money. Option A: Care pathways do not identify obstacles; staff do this. Option B: Care pathways do not stabilize aggressive clients; staff are responsible for the necessary interventions. Option C: Care pathways do not relieve nurses of the responsibility of planning; pathways may, however, make the task easier.

DIF: Cognitive Level: Application REF: Text Page: 76, Text Page: 77

TOP:Nursing Process: Implementation

MSC:NCLEX: Safe, Effective Care Environment;

2)Planning for clients with mental illness is facilitated by understanding that under behavioral health managed care, inpatient hospitalization is generally reserved for clients who

A.	are noncompliant with medication at home.
B.	present a clear danger to self or others.
C.	develop new symptoms during the course of the illness.
D.	have no support systems in the community.

ANS: B

Hospitalization is justified when the client is a danger to self or others, has dangerously decompensated, or needs intensive medical treatment. Options A, C, and D do not necessarily describe clients who would require inhospital treatment.

DIF: Cognitive Level: Application REF: Text Page: 74, Text Page: 75

TOP:Nursing Process: Assessment

MSC:NCLEX: Safe, Effective Care Environment;

3)An intervention strategy in which all psychiatric mental health nurses need to be competent and that is useful in reducing the number of clients who are admitted to psychiatric units is

A.	milieu therapy.
B.	utilization review.
C.	use of clinical pathways.
D.	community-based crisis intervention.

ANS: D

Community-based crisis intervention, by a case manager or at a crisis clinic, often resolves or manages client problems so hospitalization may be averted. Options A, B, and C refer to interventions and processes that take place after admission.

DIF: Cognitive Level: Comprehension REF: Text Page: 74, Text Page: 75

TOP:Nursing Process: Implementation

MSC:NCLEX: Safe, Effective Care Environment;

4)A client who is a member of a health maintenance organization was hospitalized after a severe reaction to a psychotropic medication. He was treated for the reaction, a new medication was ordered, and he was closely observed for side effects for 24 hours. The case manager visited before the client’s discharge to give him an appointment for an outpatient visit in 2 days and learned that the client had neglected to mention that he received notice of eviction from his apartment on the day he was admitted. The most appropriate intervention for the case manager is to

A.	cancel the client’s discharge from the hospital.
B.	file a restraining order against the landlord who evicted the client.
C.	arrange a place for the client to stay until a new apartment can be found.
D.	call the health maintenance organization and obtain permission to transfer the client to a medical unit in the hospital.

ANS: C

The case manager should intervene by arranging temporary shelter for the client until an apartment can be found. This is part of the coordination and delivery of services that falls under the case manager role. None of the other options is a viable alternative.

DIF:Cognitive Level: ApplicationREF:Text Page: 77

TOP:Nursing Process: Implementation

MSC:NCLEX: Safe, Effective Care Environment;

5)Under managed care, how are the client and family likely to view the experience of hospitalization?

A.	As an unpleasant interruption of daily life
B.	Too short to produce complete wellness
C.	Too restrictive to help with adjustment to the community
D.	A pleasant vacation from the pressures of life in the community

ANS: B

Managed care has resulted in very short hospital stays, much shorter than clients experienced in the past when discharge occurred only when the client was reasonably well suited to resume community responsibilities. Option A: Crisis situations often precede admission. Generally, both client and family are relieved. Option C: Hospitalization is currently no more restrictive or unpleasant than before the advent of managed care. Option D: Hospitalization can be guaranteed not to be long enough to be considered a vacation.

DIF: Cognitive Level: Application REF: Text Page: 74, Text Page: 75

TOP:Nursing Process: Assessment

MSC:NCLEX: Safe, Effective Care Environment;

6)A teenage client is hospitalized after a serious suicide attempt related to feelings of hopelessness. The client comes from an upper-middle-class home in the suburbs and has never had psychiatric care before. Two hours after admission, when the nurse asks about the client’s reaction to hospitalization, the client is most likely to label the experience as

A.	necessary.
B.	exciting.
C.	enjoyable.
D.	frightening.

ANS: D

Because only the most acutely ill clients are hospitalized, the client is in a milieu in which many behavioral manifestations of mental illness are apparent. The client is most likely frightened. Option A: Insight into the necessity for hospitalization only hours after making a suicide attempt is unlikely. Options B and C: Finding hospitalization enjoyable or exciting is also unlikely.

DIF: Cognitive Level: Application REF: Text Page: 80, Text Page: 81

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

7)The interdisciplinary health care team meets 12 hours after a teenage client was admitted after a suicide attempt. Members of the team report assessments. What other outcome can be expected from this meeting?

A.	A clinical pathway will be selected.
B.	The nurse will assume the surrogate mother role.
C.	The team will request a court-appointed advocate for the client.
D.	Assessment of client need for placement outside the home will be undertaken.

ANS: A

Clinical pathways are selected early in the course of treatment to streamline the treatment process and reduce costs. Option B would be inappropriate. Option C would rarely be required. Option D: It would be too early to determine the need for alternative postdischarge living arrangements.

DIF: Cognitive Level: Application REF: Text Page: 76, Text Page: 77

TOP:Nursing Process: Planning (Outcome Identification)

MSC:NCLEX: Safe, Effective Care Environment;

8)A client with a thought disorder is to be discharged home today, 4 days after having severe decompensation related to medication noncompliance. The client’s medication was restarted, and the client’s thought processes are now noted to be more logical and less interrupted by hallucinations. When the client’s husband comes to pick her up, he becomes upset and tells the nurse “She shouldn’t come home so soon. She’s still sick. You must keep her at least a month.” The nurse should

A.	call the psychiatrist to come to the unit to explain discharge rationale.
B.	explain that health insurance won’t pay for a longer stay for the client.
C.	explain that the client will continue to improve if she takes medication regularly.
D.	call security to handle the disturbance and escort the husband off the unit.

ANS: C

Under managed care clients no longer stay in the hospital until every vestige of a symptom disappears. The nurse must assume responsibility to advocate for the client’s right to the least restrictive setting as soon as the symptoms are under control and for the right of citizens to control health care costs. Option A will ultimately produce the same result because the physician will use the same rationale. Option B simply shifts blame but will not change the discharge. Option D is unnecessary; the nurse can handle the matter.

DIF:Cognitive Level: ApplicationREF:Text Page: 82

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

9)The nurse receives three telephone calls regarding a newly admitted client. The psychiatrist wishes to see the client for an assessment interview, the medical doctor wants to perform a physical examination, and the client’s lawyer wishes to set up an appointment to see the client. The nurse schedules the three activities for the client. This exemplifies the role of the nurse known as

A.	advocate.
B.	milieu manager.
C.	care manager.
D.	provider of care.

ANS: C

Nurses on psychiatric units routinely coordinate client services as described in this scenario. Option A: The role of advocate would require the nurse to speak out on the client’s behalf. Option B: The role of milieu manager refers to maintaining a therapeutic environment. Option D: Provider of care refers to giving direct care to the client.

DIF:Cognitive Level: ApplicationREF:Text Page: 78

TOP:Nursing Process: Planning

MSC:NCLEX: Safe, Effective Care Environment;

10)The nurse moves about the psychiatric unit, noting that exits are free from obstruction, no one is smoking in any area other than the smoking room, the janitor’s closet is locked, and all sharp objects are being used under supervision of staff. These observations relate to

A.	management of milieu safety.
B.	coordinating care of clients.
C.	management of the interpersonal climate.
D.	use of therapeutic intervention strategies.

ANS: A

Nursing staff are responsible for all aspects of milieu management. The observations mentioned in this question directly relate to the safety of the unit. The other options, although part of the nurse’s concerns, are unrelated to the observations cited.

DIF:Cognitive Level: ApplicationREF:Text Page: 80

TOP:Nursing Process: Implementation

MSC:NCLEX: Safe, Effective Care Environment;

11)Which aspect of direct care is the hospital psychiatric nurse most likely to provide for a client?

A.	Hygiene assistance
B.	Assertiveness training
C.	Diversional activity
D.	Assistance with job hunting

ANS: B

Assertiveness training relies on the counseling and psychoeducational skills of the nurse. The other tasks are usually performed by the lowest cost staff member who can effectively perform the task. Option A: Assistance with personal hygiene would usually be accomplished by a psychiatric technician or nursing assistant. Option C: Diversional activities are usually the province of activities therapists. Option D: The client would probably be assisted in job hunting by the social worker.

DIF: Cognitive Level: Application REF: Text Page: 76, Text Page: 77

TOP:Nursing Process: Implementation

MSC: NCLEX: Health Promotion and Maintenance

12)The nurse writes in the client’s progress notes: “3/5/year 10 AM. Client brought to unit by ER nurse. Client’s clothing and body are dirty. In interview room, client sat with hands over face, sobbing softly. Did not acknowledge nurse and did not reply to questions. After several minutes abruptly arose and ran to window and pounded window screen, shouting, ‘Let me out of here!’ repeatedly. Verbal intervention unsuccessful. Order for stat dose 2 mg haloperidol po obtained. Medication administered with result that client stopped shouting and returned to sit wordlessly in chair. Client placed on one-to-one observation until seen by psychiatrist.” How should this documentation be evaluated?

A.	Meets agency standards
B.	Contains subjective material
C.	Too brief to be of value
D.	Excessively wordy

ANS: A

This narrative note describes client appearance, behavior, and conversation. It mentions that less-restrictive measures were attempted before administering medication and documents client response to medication. This note would probably meet agency standards. A complete nursing assessment would be in order as soon as the client is able to participate. Option B: Subjective material is absent from the note. Options C and D are inaccurate evaluations based on the explanation for option A.

DIF:Cognitive Level: EvaluationREF:Text Page: 80

TOP:Nursing Process: Assessment

MSC:NCLEX: Safe, Effective Care Environment;

13)For the nurse managing the therapeutic milieu, the most heavily weighted factor in determining whether a client should receive a prn dose of neuroleptic medication is whether

A.	the client is willing to accept the medication.
B.	less-restrictive alternatives have been tried without success.
C.	the client’s behavior indicates possible danger to self, others, or the environment.
D.	administration of the medication will make the work of the staff easier or safer.

ANS: C

Although options A and B are factors to be considered, the client’s behavior is the factor of greatest importance. Option D is irrelevant.

DIF: Cognitive Level: Application REF: Text Page: 80, Text Page: 81

TOP:Nursing Process: Assessment

MSC:NCLEX: Safe, Effective Care Environment;

14)A client was admitted after police brought him to the hospital after a fight with his roommate at a community residence. The client tells the nurse that he had been suspicious for several days, then noted his roommate was casting a spell on him by looking at him intently, so he hit the roommate with his fists. The client admits he stopped taking his antipsychotic medication a week ago when the prescription needed to be refilled. Which outcome should the nurse working in a managed behavioral health inpatient unit select for this client?

A.	Symptoms will be stabilized with medication within 48 hours.
B.	A trusting relationship with the nurse will be developed within 5 days.
C.	A high level of ease with other clients will be reported within 1 week.
D.	The client will agree to placement in a new residence within 3 weeks.

ANS: A

Managed care requires the shortest possible hospital stay. Stabilization of symptoms can occur rapidly when medication is restarted. Discharge can occur shortly after stabilization. Options B, C, and D: These outcomes are inappropriate because they presume a long hospitalization.

DIF:Cognitive Level: ApplicationREF:Text Page: 82

TOP:Nursing Process: Planning (Outcome Identification)

MSC: NCLEX: Physiologic Integrity

15)The following clients are seen in the emergency department. The psychiatric unit has one bed. The advanced practice nurse acting as admitting officer should recommend for admission to the hospital the client who

A.	is experiencing dry mouth and tremor related to haloperidol and wants his dose of haloperidol reduced.
B.	is experiencing anxiety and a saddened mood after separation from her husband of 10 years.
C.	argued with her boyfriend and inflicted a superficial cut on her forearm with a knife.
D.	is a single parent and hears voices telling her to smother her infant son.

ANS: D

Admission to the hospital would be justified by the risk of client danger to self or others. The other clients have issues that can be handled without hospitalization.

DIF: Cognitive Level: Analysis REF: Text Page: 74, Text Page: 75

TOP:Nursing Process: Assessment

MSC:NCLEX: Safe, Effective Care Environment;

16)Which document pertaining to client care would a student beginning clinical experience on a psychiatric inpatient unit be justified in reading last?

A.	Clients’ Bill of Rights
B.	Unit Policy on Suicide Precautions
C.	Unit Seclusion and Restraint Policies
D.	Employee Directive on Overtime Refusal

ANS: D

Because the student is not an employee, information about overtime refusal is of less relevance. Options A, B, and C: The student will be directly involved with client rights, implementing suicide precautions, and seclusion and restraint policies.

DIF: Cognitive Level: Analysis REF: Text Page: 76, Text Page: 80

TOP:Nursing Process: N/A

MSC:NCLEX: Safe, Effective Care Environment;

17)A student nurse is assigned to administer oral medications to her assigned client. The client refuses to take the medication. The student nurse should

A.	tell the client that she will receive a poor grade if she doesn’t administer the medication.
B.	tell the client that refusal is not permitted and staff will require him to take the medication.
C.	document the client’s refusal on the medication administration record without comment.
D.	ask the client’s reason for refusing and report to the coassigned nurse.

ANS: D

The client has the right to refuse medication unless a court order to medicate has been obtained. The client’s reason for refusing should be ascertained, and the refusal should be reported to a unit nurse. Sometimes refusals are based on unpleasant side effects that can be ameliorated. Options A and B: Threats and manipulation are inappropriate. Option C: Medication refusal should be reported to permit appropriate intervention.

DIF: Cognitive Level: Application REF: Text Page: 80, Text Page: 81

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

18)Which nursing intervention is most likely to be listed in the clinical pathway as part of a basic level psychiatric nurse’s duties to a psychiatric client on day 1 of hospitalization?

A.	Provide a safe environment.
B.	Assign therapeutic activities.
C.	Order admission laboratory studies.
D.	Educate client and family about illness and medications.

ANS: A

The nurse is responsible for options A and D, but client education about illness and medications usually begins on day 2 after assessments are completed. Providing a safe environment begins at the time of admission. Option B is usually the responsibility of activities therapists. Option C would be the responsibility of a physician, physician assistant, or nurse practitioner.

DIF:Cognitive Level: ApplicationREF:Text Page: 80

TOP:Nursing Process: Implementation

MSC:NCLEX: Safe, Effective Care Environment;

19)The unit secretary is away from the unit desk, the phone rings, and the student nurse answers. The caller is the health insurer for one of the inpatients, seeking information about the client’s projected length of stay. How should the student nurse handle the request?

A.	Obtain the information from the client’s medical record and relay it to the caller.
B.	Inform the caller that information about clients is confidential.
C.	Refer the request for information to the client’s case manager.
D.	Refer the request to the unit psychiatrist.

ANS: C

The case manager usually confers with insurers and provides the treatment team with information about available resources. The student nurse should be mindful of client confidentiality and should neither confirm that the client is an inpatient nor disclose other information.

DIF:Cognitive Level: ApplicationREF:Text Page: 77

TOP:Nursing Process: Implementation

MSC:NCLEX: Safe, Effective Care Environment;

20)The nurse is surveying medical records to look for violations of client rights. The finding that would signal a violation of client rights is

A.	no treatment plan present in record.
B.	client belongings searched at admission.
C.	physical restraint used to prevent harm to self.
D.	client was placed on one-to-one continuous observation.

ANS: A

The client has the right to have a treatment plan. Option B: Inspecting client belongings is performed as a safety measure. Clients have the right to a safe environment. Options C and D: Clients have the right to be protected against the possible impulse to harm oneself that occurs as a result of a mental disorder.

DIF:Cognitive Level: AnalysisREF:Text Page: 76

TOP:Nursing Process: Evaluation

MSC:NCLEX: Safe, Effective Care Environment;

21)When responding to a client who exhibits agitated, hostile behavior during a community meeting, the initial action the nurse should take is to

A.	offer prn medication.
B.	follow the treatment plan.
C.	place the client in seclusion.
D.	permit the angry outburst if no harmful behavior is threatened.

ANS: B

Consistency in response is vital to positive outcomes; hence, following the treatment plan is the correct answer. The response of staff might take different forms depending on the treatment plan.

DIF:Cognitive Level: ApplicationREF:Text Page: 81

TOP:Nursing Process: Implementation

MSC:NCLEX: Safe, Effective Care Environment;

22)A student nurse tells the instructor “I don’t feel as though I’m helping my assigned client. I don’t have the opportunity to engage him in formal counseling sessions. I only spend time with him as he has time between appointments.” The best reply for the instructor would be

A.	“It is appropriate for beginners to progress slowly and develop skills.”
B.	“It’s all new to you. By the end of your second week on the unit you will find you feel more helpful.”
C.	“I’m sorry you’re feeling disappointed. Have you considered whether your goals for the experience were realistic?”
D.	“In informal contacts your psychosocial communication skills help him feel listened to and supported. You provide feedback and encourage use of adaptive coping skills.”

ANS: D

Nurses should be aware that informal contacts are often as significant as formal contacts because they occur during natural activities of daily and social living and are therefore based on reality.

DIF:Cognitive Level: ApplicationREF:Text Page: 79

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

23)Which of the following would the psychiatric nurse assess as a behavioral crisis? A client is

A.	found crying hysterically after receiving a phone call from her boyfriend.
B.	noted curled up in a corner of the bathroom with a towel wrapped around her head.
C.	performing push-ups in the middle of the hall, forcing everyone to walk around him.
D.	waving his fists and shouting threats at a nurse who offered him prn medication.

ANS: D

This behavior constitutes a behavioral crisis because the client is threatening harm to another individual. Intervention is called for to defuse the situation. The other options speak of behaviors that may require intervention of a less urgent nature because the clients in question are not threatening harm to self or others.

DIF:Cognitive Level: AnalysisREF:Text Page: 81

TOP:Nursing Process: Assessment

MSC:NCLEX: Safe, Effective Care Environment;

24)Which principle should be followed by psychiatric inpatient staff when addressing a behavioral crisis?

A.	Resolve it with the least restrictive intervention possible.
B.	Individual client rights are superseded by the rights of the majority.
C.	Swift intervention is preferable to planned, structured intervention in nearly all instances of dyscontrol.
D.	Allow the client the opportunity to regain control without intervention when safety of other clients is not compromised.

ANS: A

The rule of using the least restrictive treatment or intervention possible to achieve the desired outcome is the client’s legal right. Option B: This is not strictly true. Option C: Planned interventions are nearly always preferable. Option D: Intervention may be necessary when the client is threatening harm to self.

DIF:Cognitive Level: AnalysisREF:Text Page: 81

TOP:Nursing Process: Implementation

MSC:NCLEX: Safe, Effective Care Environment;

25)When the clinical nurse leader is asked to defend the use of clinical pathways to a hospitalwide committee, which should be stated as an advantage? Clinical pathways

A.	obscure resource management.
B.	deter collaborative practice.
C.	are generic rather than individualized.
D.	make it easy to monitor treatment progression.

ANS: D

When treatment and outcomes are projected on a day-to-day basis, monitoring and outcome evaluation are simplified. Exceptions are quickly noted. This is of considerable advantage to the treatment team. Option A: Pathways actually facilitate resource management, particularly in the area of staffing. Option B: Pathways support collaborative practice. Option C: Generic treatment plans are useful because they are evidence based and complete plans for a client with a specific disorder. They can easily be modified to meet individual needs.

DIF: Cognitive Level: Application REF: Text Page: 76, Text Page: 77

TOP:Nursing Process: N/A

MSC:NCLEX: Safe, Effective Care Environment;

26)A new client asks the nurse “So what goes on at this community meeting scheduled this afternoon?” The best reply by the nurse would be

A.	“You and your therapist will discuss problems and goals for problem resolution.”
B.	“You and a small group of other clients will meet to discuss common issues.”
C.	“You, the staff, and the other clients will meet to discuss problems occurring on the unit.”
D.	“We never know what will go on at a community meeting because clients determine the agenda.”

ANS: C

Community meetings involve staff and clients. Items pertinent to the functioning of the community are topics for exploration. Ideas for activities, community problems, clarifications of unit rules, greeting new clients, and saying goodbye to clients being discharged might be included. Option A describes individual therapy. Option B describes group therapy. Option D is evasive.

DIF:Cognitive Level: ApplicationREF:Text Page: 79

TOP:Nursing Process: Implementation

MSC:NCLEX: Safe, Effective Care Environment;

OTHER

1)A group of nurses at the managed behavioral health organization have the task of revising the current admission criteria.

1. Clear risk of client danger to self or others

2. Dangerous decompensation of a client under long-term treatment

3. Failure of community-based treatment demonstrating clear need for intensive, structured treatment

4. Medical need unassociated with psychiatric treatment or associated with treatment

5. Provision of respite for caregivers

Which, if any, of the criteria should be deleted?

A. none

B. 1

C. 2

D. 3

E. 4

F. 5

ANS:

E

Rationale: The goal of caregiver respite can be accomplished without hospitalizing the client. The other options are acceptable, evidence-based criteria for admission of a client to a managed behavioral health organization.

DIF: Cognitive Level: Application REF: Text Page: 74, Text Page: 75

TOP:Nursing Process: Implementation

MSC:NCLEX: Safe, Effective Care Environment;

2)The psychiatric nurse should plan interventions based on the knowledge that clients may be intolerant of, or resistant to, common procedures such as vital signs, blood glucose monitoring, or insulin administration. Common reasons for resistance include (more than one answer may be correct) 

A. anxiety.

B. obstinacy.

C. lack of trust.

D. thought impairment.

ANS:

A, C, D

Rationale: Resistance to routine procedures is rarely related to the psychiatric client being perverse or having an uncooperative personality trait. More often resistance is related to anxiety, fear, suspicion, cognitive impairment, or lack of knowledge.

DIF: Cognitive Level: Analysis REF: Text Page: 80, Text Page: 81

TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity

3)A nurse performed the following actions and interventions in the course of a day while caring for a client with psychosis:

1. Removed embroidery scissors from client’s possession

2. Arranged for client to make an appointment with a lawyer

3. In client’s presence, opened a package mailed to client

4. Remained within arm’s length of client during the shift

5. Permitted client to refuse oral psychotropic medication

Which intervention, if any, violated a right of the client?

A. none

B. 1

C. 2

D. 3

E. 4

F. 5

ANS:

A

Rationale: Actions 1 and 4 preserve the client’s right to be protected against the possible impulse to harm self or others. Action 2 preserved the client’s right to legal counsel. Action 3 preserved the client’s rights to send and receive mail and be present during package inspection. Action 5 preserved the client’s right to refuse treatment.

DIF:Cognitive Level: AnalysisREF:Text Page: 76

TOP:Nursing Process: Implementation

MSC:NCLEX: Safe, Effective Care Environment;

4)The nurse observes a client’s anger escalating. He begins to pace the hall and shouts “You all had better watch out. I’m going to hurt anybody who gets in my way.” Assuming each of the following interventions is appropriate, put them in the order in which they should occur. (Type answer in order from first to last.)

A. Take the client to a seclusion room and administer medication.

B. Have a nurse prepare prn medication.

C. Calmly tell the client that “staff will help you control your impulse to hurt someone.”

D. Gather a show of force.

E. Remove clients from the area.

ANS:

E, C, B, D, A

Rationale: The ideal sequence provides a rapid, organized response that provides safety for the other clients and progresses from verbal limit setting to immobilization and concurrent use of medication.

DIF:Cognitive Level: AnalysisREF:Text Page: 81

TOP:Nursing Process: Implementation

MSC:NCLEX: Safe, Effective Care Environment;